Terraces at Via Verde-a Memory Care Community, the.

The investigation revealed the following: regarding the allegation “Staff installed cameras in resident rooms preventing them from having a reasonable level of personal privacy in their accommodations.” It is alleged the facility installed cameras in residents’ rooms. Four (4) out of the four (4) staff interviewed denied the allegation. Interview with S1 revealed the facility installed fall detection sensors in residents’ rooms and not video cameras. S1 revealed these fall detection sensors do not record video or audio. Interview with S2 revealed that fall detection monitors were installed in November 2025 but are not yet operational. S2 revealed the fall detection sensors will send a notification if it senses a sudden stop in movement or jolt. S2 revealed all residents’, and their families were notified in writing about the fall detection sensors in November of 2025. S2 revealed all fall detection sensors will be operation once all staff are trained. Review of records revealed a letter addressed to resident families regarding fall detection sensor installation in or around November 24, 2025, and the benefits of the fall detections sensors. During facility tour, S1 showed LPA the fall detection sensors in resident rooms. LPA Ramirez observed these sensors with a cover blocking the lens. According to S1 the sensors are all covered and not yet being operational. S1 revealed that residents and their families will sign consent forms before the fall detection sensors are operational. LPA Ramirez attempted to interview four (4) residents, due to cognitive impairments, these interviews were unreliable. 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 .

The Investigation Revealed the following: Allegation: Questionable death. It is alleged that R1's death is questionable due to being over medicated. This allegation was investigated by IB Investigator A.Luckett who began the investigation on 2/7/25. On 3/6/25 IB Investigator A.Luckett went in person to the Pasadena Public Health Department and obtained a copy of R1's Death Certificate with a date of death of 2/3/25 and cause of death listed as: Cardiac Arrest and Alzheimers Disease. On 3/11/25 a request for R1's toxicology report was sent. On 12/17/25 IB Investigator A.Luckett received the toxicology report, the laboratory results that were completed on 2/10/25 showed that tests completed on medications were Not Detected. After a thorough review of documents obtained, IB investigator A.Luckett did not see anything unusual or concerning with the cause of death. Based on statements and interviews conducted, review of R1's file, facility records and medical records by IB investigator A.Luckett, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided.

The investigation revealed the following: Allegation: Facility staff did not dispense medications as prescribed. It is alleged that staff at facility were not dispensing resident’s medications as prescribed and administered PRN to R1 without consulting with responsible party before or after administering the medication. LPA conducted medication review, a total of 5 resident medications were reviewed with no issues observed. LPA reviewed R1’s MAR (Medication Administration Record) and did not observe any issues notations of medication being administered outside of the doctors’ instructions. LPA interviewed 4 staff and each denied the allegation, interviews with S3-S5 revealed that the Medication System that is used is very precise and does not allow medications to administer a medication before the allowed time. Staff also stated that contacting responsible parties is not a requirement when administering PRN unless the resident is not responding well to the medication, in which they will call family/responsible party/doctor and meet with them to create a plan/medication routine that will work best for the resident. LPA interviewed 5 residents and each denied the allegation and stated they do not have issues with the medication and believe medication is being given to them as prescribed. Allegation: Resident sustained unexplained injuries in care. It is alleged that R1 had an unwitnessed fall, sustained injuries from the fall and could not provide reasons or details of what happened. LPA reviewed R1’s file and within the Charting Notes (observations) R1 experienced a fall on 1/27/25 where resident was observed on floor near bed at 9pm with redness on right hip area and no major injuries, it is noted that family were contacted about the fall. LPA interviewed 4 staff and each denied the allegation and stated that falls at the facility are always documented and reported to the resident’s family and doctor (hospice if needed). Staff stated that residents are monitored post fall at all times and if the resident is injured, hits their head or complains of pain they call 911 to have the resident accessed. LPA interviewed 5 residents, and each denied the allegation and stated they have not had any unexplained injuries at the facility. (Continued on LIC9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Facility staff did not ensure that resident was adequately fed. It is alleged that R1 was not adequately fed and appeared extremely thin. LPA reviewed R1’s file and observed that there were no major fluctuations in weight from admission to discharge (November 2024-January 2025) with weight beginning at 84.5lbs (admission weight) and ending at 84.1lbs (discharge month weight). LPA interviewed 4 staff and each denied the allegation and stated the residents are being fed well with meals and snacks provided. Staff stated that there is a meal record kept for each residents that will monitor if they have a loss of appetite and when that is noticed the family and doctor are notified. LPA asked Suby for a copy of the meal chart for R1, however, this is a new procedure that began in April 2025, 3 months after R1 was discharged from facility. LPA interviewed 5 residents and each denied the allegation and stated that they like the food and are provided with 3 meals a day and snacks are offered throughout the day. Additionally, LPA reviewed the food menu and food supply and did not see any issues, snacks were being prepared during visit and included ice cream with chocolate syrup, fruit and yogurt, meal served for lunch was a BBQ Chicken Sandwich with Baked Beans and Coleslaw. Allegation: Facility staff did not ensure that resident had clean linens. It is alleged that facility staff left R1’s bed soaked in urine. LPA toured facility, a total of 5 resident rooms were entered and LPA observed all rooms to be clean with clean/dry linens, no foul odors were observed and spare clean linens were stored in resident closets along with incontinence supplies. LPA observed a sufficient amount of incontinence care items in the facility storage. LPA interviewed 4 staff and each denied the allegation and stated that when a residents linens are soiled the caregivers immediately strip down the bed and wash the linens, and prepare the residents bed with the spare clean linens. Staff stated that there are weekly linen changes, however, the linens will also be changed on an as needed bases. LPA interviewed 5 residents and each denied the allegation and stated that their rooms and bed are maintained clean and do not have any issues with linens being soiled. Based on statements and interviews conducted with staff/residents, review of R1's file and facility records, there was not enough supportive evidence to concur with the reported allegations. 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, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced Case Management Visit-Incident on 10/30/2025, stemming from incident report received on 10/16/2025. LPA was greeted by Director of Nursing Nicole Stinson and the purpose of the visit was explained. During today’s visit, LPA Gonzalez toured the facility’s medication room, obtained staff and client rosters, obtained copies of documents related to the incident, interviewed staff #1-3 (S1-S3) and residents #1-2(R1-R2). According to LIC 624- Unusual Incident/Injury Report received on 10/16/2025, staff self-reported that during a routine medication audit, it was discovered that R1 was not administered morning medications. Staff interviews and record review revealed the facility schedules two (2) med techs per shift and one (1) overnight. On the morning shift of 09/02/25, S2 observed morning medications had not been administered for R1 on 09/01/25. S2 immediately informed S1. R1’s doctor and family were also notified. R1 was monitored and did not have any adverse reaction and remained in stable condition. No further action is required at this time. LPA Gonzalez may return to gather additional documents. No deficiencies were cited during today's visit. Exit interview was conducted. A copy of this report was provided to Director of Nursing Nicole Stinson.

Regarding allegation: Staff did not check on residents in a timely manner It is alleged that staff did not ensure resident’s well-being when resident had fallen to the ground. Staff did not respond in a timely manner to aid residents, instead another resident provided assistance to a resident who had fallen. The investigation reveals the following: Residents interviews revealed that four (4) out six (6) stated that they have not experienced any issues with staff responding in a timely manner. The remaining two residents were unable to respond to LPA’s question. R1 stated that R1 has used the bathroom call button and staff has responded to provide assistance. LPA interviewed R1, who stated that there was one instance where R1 had fallen in R1’s bathroom. R1 yelled out for assistance since the call button was out of R1’s reach, however, staff managed to hear R1’s calls for assistance and provided R1 with assistance. Staff interviews revealed that six (6) out of six (6) staff denied not responding to residents’ calls in a timely manner. LPA observed that during facility activities staff were providing assistance to residents in the common area. LPA tested call buttons in two random residents’ rooms, and the response time was less than five (5) minutes. Staff stated that wellness checks are done every two hours, but if residents have special needs, wellness checks are done more frequently. Based upon the investigation, client and staff interviews, and LPA observations, there was insufficient evidence to corroborate the allegation. Regarding allegation: Staff inappropriately removed the signal systems from residents’ rooms. It is alleged that the signal system pull cords have been removed from residents’ rooms and bathrooms and that residents may not be able to summon staff for assistance when needed. The investigation reveals the following: The signal system was replaced in May/June; however, the new system was operational on the same day that the previous signal system was removed. There was no downtime experienced at the facility during installation and replacement of signal system. Residents’ interviews revealed that three (3) out of six (6) residents stated that they have not needed to use the call button to summon staff for assistance. R1 stated that R1 has used the bathroom call button and staff has responded to provide assistance. R1 stated that there was one instance where R1 had fallen in R1’s bathroom. R1 yelled out for assistance since the call button was out of R1’s reach, however, staff managed to hear R1 calls for assistance and provided R1 with assistance. Two (2) out of six (6) residents were not able to understand questions about the call system. LPA tested the call system on each floor and staff responded in a timely manner, in less than five (5) minutes. Staff interviews revealed that six (6) out of six (6) staff denied not responding to residents’ calls when the signal system button is pressed. CONTINUED ON LIC-9099C 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 observed signal system application on each caregiver mobile phone. The caregiver was able to reset call alert only when the caregiver was physically in the room and press the same call button where the alert was activated. Executive Director Kumar explained that all managers have access to mobile signal system alerts and if a caregiver does not respond in a timely manner, the managers will contact the caregiver directly to respond to the signal system call even after business hours. Based upon the investigation, client and staff interviews, and LPA observations, there was insufficient evidence to corroborate the allegation. Regarding allegations: Staff are not answering the facility phone. It is alleged that the facility is not answering the facility phone. The investigation revealed the following: During business hours, the facility has a receptionist at the front desk answering incoming phone calls. Staff stated that managers will answer phones if the receptionist steps away from the front desk. For after-hour shifts, the main phone line is transferred to night shift MedTech who is responsible for answering the phone. Executive Director Kumar explained that if the main phone line is busy, residents’ families or responsible party may call the facility’s nurse phone line that is available 24x7. In addition, the facility has provided families and/or residents responsible parties with phone numbers of all managers. R1’s trustee confirmed that the trustee had the managers’ phone numbers. Residents interviewed revealed that four (4) out of six (6) residents do not receive phone calls since they don’t have anyone that would call residents. Two (2) out of six (6) residents stated that family prefers to visit them. Staff interviews revealed that six (6) out of six (6) staff denied not answering phone calls. MedTech confirmed that phone calls are transferred to MedTech mobile phone. Staff stated that phone calls may not be answered if the line is busy with another call. However, staff stated that it is unusual to receive telephone calls at night. During the visit, LPA observed that telephone calls were being answered by receptionist. Based upon the investigation, client and staff interviews, and LPA observations, there was insufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . Exit interview was held with Executive Director Subashsani Kumar. A copy of the report was provided.

During today's visit, LPA obtained the following documents: staff and client rosters. Regarding allegation: Licensee does not provide a safe environment for residents in care. it is alleged that a resident is abusing another resident and staff are not addressing the resident’s behavior, which is creating an unsafe environment for residents in care. Six (6) out of nine (9) staff interviewed denied the allegation. Two (2) out of nine staff interviewed corroborated the allegation and stated being concerned about the multiple occurrences of R1’s physical altercations with R3. One (1) out of nine (9) staff interviewed could not confirm nor deny the allegation. However, nine (9) out of nine (9) staff stated that if residents are involved in an altercation, the staff would immediately intervene, separate, and re-direct the residents being involved. Nine (9) out of nine (9) staff stated that there have been no reported injuries from any resident-on-resident physical or verbal altercations. Nine (9) out of nine (9) staff stated that R1 only able to speak a different language which causes R1 to become more agitated and become physically aggressive. However, nine (9) out of nine (9) staff stated that R1’s family does visit daily and also able to help communicate by the phone to provide assistance. Executive Director also stated that they use their cellphone apps to help communicate with R1. Based on record review, R1’s current physician’s report does not have a history of aggressive behavior. However, R1’s Pre-placement appraisal does state mild nervousness or anxiousness. The Executive Director and (2) out of eight (8) staff stated that R1 is adjusting due to recently moving into the facility and that medications taken also take time for R1 to become stable. Executive Director confirmed that in order to ensure safety, R1 and R3 were moved to different rooms on 05/28/2025. Executive Director stated that if resident’s aggressive behavior continues, they would continue to address and work with residents who have aggressive behaviors. Executive Director stated that R1 moved out of the facility on 06/06/2025. Five (5) out of five (5) residents interviewed denied the allegation and stated that they feel safe at the facility. None of the residents interviewed stated being physically or verbally abused by another resident or staff. Based on interviews conducted with facility staff, facility client, witnesses, and record review, there was not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided to the Executive Director, Subishsani Kumar.

(continued from 9099) LPA interviewed six (6) staff and three (3) of six (6) staff members denied the allegation. Three (3) staff members stated that occasionally they will discover resident in soaking wet diapers. One (1) staff member stated that is not very often and that it is just one resident who may be too heavy and burdensome to tend to. LPA interviewed four (4) witness, two (2) are family members and all four (4) witness stated that witnesses do not have any evidence of residents left in wet diapers. One (1) witness stated things have improved since witness verbally brought the issue to staff and stated that witness has no issues with the care at facility at this time. LPA did not observe any residents with bad odor and all the residents. LPA observed residents were clean and in clean clothes during the visit. LPA reviewed the May 2025 Electronic Charting Program (ECP) for three residents in question, and it showed that staff are making their rounds, and providing residents hygiene and bathing services and documenting it on the ECP. LPA observed the rooms to be very clean. LPA observed staff providing care and activities for residents during the visit. There is not sufficient evidence to substantiate this allegation. Allegation: Staff did not ensure resident's showering needs were met. It is alleged that residents are not being showered as required. LPA interviewed eight (8) residents, and all eight (8) residents were not able to corroborate the allegations. LPA interviewed six (6) staff and five (5) of six (6) staff denied the allegations. All staff stated they provide showering for all residents unless they refuse. LPA interviewed four (4) witness and four (4) of four (4) were not able to corroborate the allegation. LPA reviewed the May 2025 Electronic Charting Program (ECP) for three residents in question, and it showed that staff are making their rounds, and providing residents hygiene and bathing services and documenting it on the ECP. LPA observed all residents to be clean and did not omit and body odor. Two (2) residents stated that they bathe themselves. LPA observed that the showers in most rooms inspected were recently used as there was current water residue left behind in the shower and adjacent floor that provided evidence that residents are being showered. There is not sufficient evidence to substantiate this allegation. 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, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with the Executive Director, Suby Kumar. A copy of this report, along with the appeal rights, was provided.

Staff stated the residents come out to the communal area (dining area) to do activities and have their meals. For those who choose to remain in their rooms, staff would do room checks at least every 2 hours. Staff indicated that all employees, including kitchen, housekeepers, and maintenance, are also monitoring residents as they are doing their duties. If they see anything usual with the residents, they will ask caregivers or med techs to assist the residents. According to staff, most of the residents go out to the dining area for their meals. They know which residents have a restricted diet and kitchen staff are aware of their diets and allergies. They monitor if residents are eating and ensure they are given their proper restricted diets. LPA interviewed 4 residents, and they all stated that the staff provide good care and supervision. There is always a staff available when needed. Staff bring them out to the common area and supervise them during mealtime. 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. An exit interview was conducted with the Executive Director. A copy of this report, along with the appeal rights, was provided.

The investigation revealed the following: In regards to the allegation: "Staff transported a resident to a different hospital emergency room." It is alleged that R1 was taken to the hospital on 11/27/2024 where family members waited for 2 hours, but later found out that R1 was moved to a different emergency room after they called the facility several times for confirmation. (3) out of (5) staff remembered an incident where upon leaving the facility, paramedics informed the facility staff that R1 will be taken to Pomona Valley Hospital, which was then communicated to the family. However, the facility did not receive calls from the paramedics nor the hospital regarding the hospital change. (5) staff interviewed indicated that location changes can happen, but it is the responsibility of the paramedics or hospital staff to inform the family/POA or responsible party or facility staff about such changes. (5) residents interviewed had no comments about the allegation as they were unaware of the incident. Based on records reviewed, former Administrator had informed a family member on 12/04/2024 that R1 was meant to be transported to Pomona hospital. However, while en route, R1 was redirected to a different hospital and the facility did not receive this information from the paramedics, hence was not shared to the family member. Therefore, there was insufficient evidence to corroborate with the allegation. In regards to the allegation: "Staff left harmful material accessible to a resident." It is alleged that a resident had dinner and placed a urine bag on the table while another resident ate nearby. All staff interviewed denied seeing or hearing about this incident. (5) out of (5) staff interviewed stated that they would never allow such a situation to happen and they are committed to maintaining a clean dining environment to ensure safety and prevent contamination. (5) out of (5) residents interviewed cannot corroborate the allegation. All (5) residents stated that they did not witness or hear anything related to the incident. LPA observed the dining area to be clean and no urine bag was seen on the dining table. Therefore, there was insufficient evidence to corroborate with the allegation. 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 In regards to the allegation: "Staff did not meet a resident's catheter needs while in care." It is alleged that during the week of 01/06/2025, a resident was seen walking barefoot while dragging what appeared to be a urine bag attached to a catheter. All staff interviewed denied seeing or hearing about this incident. Staff interviewed denied knowing about the incident and stated they prioritize resident safety, including protecting catheters. Staff also stated that their job is to assist all residents in the community to ensure they are not at risk of tripping or falling and if they have seen such an incident, that they will assist the resident immediately. (5) out of (5) residents interviewed denied seeing anyone dragging a urine bag. All residents interviewed stated that if they have seen it, they will call someone or a caregiver to help the resident. LPA did not observe any resident walking barefoot with visible urine bags. Therefore, there was insufficient evidence to corroborate with the allegation. Based on observations, statements and interviews conducted with staff, residents and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Subishsani Kumar, Executive Director.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Environmental Director of Services- Mark Chisum and purpose of today’s visit. This facility is licensed to serve sixty (60) non-ambulatory residents and all bedrooms are approved for non-ambulatory. This facility may retain no more than twenty (20) hospice residents. There are six (6) residents under hospice care at this time. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected eight (8) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. The facility is approved for delay egress doors. LPA Ramirez tested and observed doors to be in good repair. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Planned Activities: Facility has an activities director and LPA Ramirez observed staff conducting seated exercises with residents during physical plant tour. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. Last documented emergency drills were conducted on 06/26/2024 and 05/23/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. SEE 809-C for continuation of report 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 Residents with Special Needs : No large bodies of water or pools were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps, or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for Robert Jakini expires 07/24/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for five (3) out of the five (5) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for five (5) out of the five (5) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for sixty (60) non-ambulatory. This facility may retain no more than twenty (20) hospice residents. There are six (6) residents under hospice care. Resident Records/Incident Reports: LPA reviewed Resident files for eight (8) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were cited during this inspection. Exit interview was conducted and a copy of this report was provided via email due to printer problems.

The investigation revealed the following: in regard to the allegation " Staff mismanaged residents' medication.” It is alleged that medication administered without proper sign offs and medication being shared between patients / residents. Interviewed Administrator and staff denied the allegation. They stated that staff did not shared medications between residents and all medications are administrated as prescribed and are noted electronically through a "Quick MAR" program. All residents’ medications are registered under the "Quick MAR" program. However, staff indicated they only have written MARs for new residents until their profile will be created in the system. All medications are administered on a consistent schedule. When residents refuse medication, Med Tech / LVNs document refusals, contact Resident's responsible party and contact the Prescribing Physician. Interviewed staff demonstrated to LPA how is worked "Quick MAR" program. LPA observed that residents medications are registered under the "Quick MAR" program. LPA also reviewed written MAR and observed medications are documented properly and given as prescribed. Residents interviewed stated that staff administrated medication. They were unable to provide other information due to their diagnosis. Administrator and staff indicated that each Med. Tech. / LVNs have their own log in passwords. The information gathered does not corroborate the allegation noted above. 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. An exit interview was conducted and a copy of this report was provided Administrator Robert Jakini

On 6/3/24, LPA Flores contacted Guardian Pharmacy. On 6/11/24 LPA Flores delivered findings for complaint. The investigation revealed the following: Regarding allegation: Facility did not notify appropriate doctor of resident’s change in condition. It is alleged incorrect doctor was notified of resident’s change in condition. Record review revealed that upon R1’s return to the facility on 6/3/22 family representative notified facility of change of physician. The change was noted in the facility’s face sheet under resident’s contacts – medical, previous physician was crossed out and new physician was written in ink with contact phone number. On 6/7/22 facility staff notified a different physician of change in condition per records reviewed. The physician notified was not previous or R1’s current physician. Per interviews conducted with staff, physician notified is not under the same medical group as R1’s physician at the time. Staff also stated that any changes are noted in the hard copy file as well as the facility’s digital database. The facility staff that notified the physician does not recall the incident. However, per records reviewed the staff made a mistake and notified the wrong physician. Notes revealed physician who was notified, then contacted the correct physician of R1’s change in condition. Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Robert Jakini and a copy of this report, LIC 9099D, 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 6/3/24, LPA Flores contacted Guardian Pharmacy. On 6/11/24 LPA Flores delivered findings for complaint. The investigation revealed the following: Regarding allegation: Resident suffered a fracture while in care due to lack of supervision. It is alleged that on 4/11/22, while under the care of the facility R1 fell, was transported to the hospital where R1 was diagnosed with a hip fracture. Documents reviewed revealed the following: R1 was admitted to the facility on 3/25/22. Preplacement Appraisal Information dated 3/20/22 notes R1 requires checks due to not being able to balance. There is no previous history of falls recorded on preplacement appraisal or needs and care plan. Per physician’s report dated 8/4/21, R1 does not have any motor impairment or history of falls. Per incident report dated 4/16/22, on 4/11/22 R1 had an unwitnessed fall in R1’s room at around 6:45pm. Facility staff contacted 911 “immediately” and notified R1’s representative and physician. Medical Records revealed R1 was hospitalized on 4/11/22 due to a mechanical fall which resulted in a left proximal femur fracture. Per interviews with staff, R1 was last seen in the dining room around 5:00pm and went back to the room. Staff conducts checks on residents at least every 2 hours or based on each individual needs. R1 was heard screaming and therefore a staff that was walking by heard R1 and responded to R1. Although, R1 did sustain a fracture during the fall, there is insufficient evidence that R1 required assistance due to a history of falls or that there was no staff to provide assistance. 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 . Regarding allegation: Staff did not notice a change in resident's condition. It is alleged during the 4 days from June 3rd to June 7th R1’s condition deteriorated with a weight loss of 12 lbs. Records reviewed revealed R1 was hospitalized on 4/11/22 due to a fracture. On 4/18/22, R1 was discharged to a skilled nursing facility. On 4/28/22, R1 was hospitalized due to severe anemia. On 4/19/22, Skilled nursing noted R1’s weight as 156 lbs. On 5/18/22, skilled nursing noted abnormal weight loss for R1. On 5/20/22, skilled nursing noted R1 had lost 10 lbs. On 5/31/22, R1’s weight was noted as 152 lbs. R1 was discharged from skilled nursing to residential facility by physician on 5/31/22, “The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility”. On 6/2/22, Physician ordered to discharge R1 to residential facility. On 6/3/22, R1 was re-admitted to residential facility. On 6/4/22, facility staff noted R1 refused a meal. On 6/5/22, facility staff noted R1 has a decrease of appetite and noted that Health Residential Services (HRS) staff will continue to monitor R1. On 6/6/22, facility staff noted that R1 had refused meals. (CONTINUED ON LIC 9099C) 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 6/7/22, physician and R1’s representative was notified of R1’s change in condition. R1’s physician visited R1 and by 4:30pm R1 was transferred back to Skilled Nursing Facility per physician’s request. On 6/8/22 it was noted by Skilled Nursing staff that R1 was weighing 140 lbs. Although R1 did lose 12 lbs. between 5/31/22 and 6/8/22, R1 had a history of abnormal weight loss. Weight loss began in SNF and was noted as abnormal weight loss during the stay at the SNF. In addition, R1 had a history of anemia. Per records review facility staff encouraged R1 to eat meals between 6/3/22 and 6/6/22. However, R1 refused meals on 6/6/22 and facility staff notified physician within 24 hours of R1 refusing meals. Interviews with staff revealed that when residents refused a meal staff notifies HRS to monitor and once a resident continues to refuse all three meals staff notifies physician. Facility staff followed the facility’s procedures for the change in condition. 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. Regarding allegation: Resident developed a wound while in care. It is alleged R1’s surgical wound re-opened, new wound on lower back, and a hematoma on heel of left foot was discovered once arrived at SNF. On 4/11/22, R1 was hospitalized due to hip fracture and required surgery. On 4/27/22, Advantage Wound Care was in place for R1, who provided care for wound on left hip and thigh upper area for surgical wounds. On 6/1/22, Advantage Surgical Wound Care visited R1 and managed wounds in multiple locations which were not described in records reviewed. On 6/3/22, facility noted that R1 is receiving wound care for a stage 2 wound upon readmission. The location of the wound was not identified. On 6/7/22, R1 was readmitted to SNF. On 6/8/22, SNF staff noted the following regarding R1’s skin. R1 had “multiple sites of skin discoloration; left hip surgical wound, sacrum pressure Deep Tissue Injury (DTI), right 1st toe trauma, and left heel DTI”. Physician noted care for R1 to monitor left heel for signs of infection, monitor surgical hip for signs of infection, monitor right toe, and order heel protectors to prevent from opening. On 6/15/22, Advantage Surgical and Wound care notes the following four wounds “(1) pressure left heel DTI no drainage, (2) surgical left hip wound was resolved, (3) pressure sacral coccyx DTI debris, surgical, and (4) trauma to right 1st toe no drainage and monitor”. On 6/15/22, pressure sacral coccyx developed into a stage 3 wound. Based on documents reviewed, R1 had two surgical wounds when admitted at SNF on 4/18/22 for which R1 was receiving care. On 6/1/22, R1 continued to receive care for surgical wound. On 6/3/22, facility noted the surgical wounds. On 6/8/22, R1 had three sites of deep tissue injury. (CONTINUED ON LIC 9099C) 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 However, the sites were not staged. The sacral coccyx wound got first stage on 6/15/22 while R1 was at the skill nursing. Therefore, there is not enough evidence to say that R1’s wounds developed while in care at the facility. Deep Tissue Injuries(DTI) can develop as soon as within 24 hours due to friction while moving or transferring a resident. R1 returned to skill nursing on 6/8/22 and did not return to the facility. Therefore, it cannot be determined that DTIs were caused by a lack of care of facility staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegations: Facility did not administer medications to resident and Facility did not ensure resident's medications were ordered. It is alleged R1’s responsible party provided physical list of updated medications to facility’s management staff (Staff #2 S2) and the listed medications were not ordered or administered to R1. Document review revealed the following, on 6/3/22, R1 returned to residential facility after being discharged from SNF. Facility’s medication sheet for June 2022 lists a total of 21 medications, of which 9 were started on 6/7/22. On 6/3/22, SNF medication listed 17 medications at the time of discharge. The additional medications observed were vitamins and an antibiotic. Interviews conducted with facility staff revealed facility works with a pharmacy which provides the profile and dispenses the medication. Once the entry of the medication list is inputted the medication is then ordered and delivered to the facility. Delays of medication are usually caused by medication error or new orders that need to be verified with the physician. Per staff, R1 came with some medication which was noted in the medication sheet. Interview with pharmacy representativ

The investigation revealed the following: in regard to the allegation " Staff mismanaged residents' medication.” It is alleged that medication administered without proper sign offs and medication being shared between patients / residents. Interviewed Administrator and staff denied the allegation. They stated that staff did not shared medications between residents and all medications are administrated as prescribed and are noted electronically through a "Quick MAR" program. All residents’ medications are registered under the "Quick MAR" program. However, staff indicated they only have written MARs for new residents until their profile will be created in the system. All medications are administered on a consistent schedule. When residents refuse medication, Med Tech / LVNs document refusals, contact Resident's responsible party and contact the Prescribing Physician. Interviewed staff demonstrated to LPA how is worked "Quick MAR" program. LPA observed that residents medications are registered under the "Quick MAR" program. LPA also reviewed written MAR and observed medications are documented properly and given as prescribed. Administrator and staff indicated that each Med. Tech. / LVNs have their own login passwords. The information gathered does not corroborate the allegation noted above. 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. An exit interview was conducted and a copy of this report was provided Robert Jakini.

The investigation revealed the following: Regarding the allegation " questionable deaths ”, it is alleged that Resident 1 (R1) - Resident 6 (R6) did not seem to be ill and upon developing a medical diagnose they passed away within days. Complainant is not aware if any of the residents had any underlining conditions. Staff interviewed stated these residents had underlying conditions and were placed on hospice, and that their death were not due to neglect. Review of records all residents were on hospice. LPA obtained copies of death certificates for all residents. R1 (80 years old) passed away on 06/12/2022: immediate cause of death was cardiopulmonary arrest, and the underlying causes were acute respiratory failure and Covid-19. R2 (86 years old) passed away on 06/06/2022: immediate cause of death was Alzheimer’s Disease. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. R4 (84 years old) passed away on 12/05/2021: immediate cause of death was cardiopulmonary arrest, and the underlying cause was senile dementia. R5 (82 years old) passed away on 03/17/2022: immediate cause of death was cardiopulmonary arrest, and the underlying cause were urosepsis and atherosclerosis of coronary artery. R6 (83 years old) passed away on 12/18/2021: immediate cause of death was cardiac arrest, and the underlying cause were respiratory failure and Parkinson’s disease. Residents interviewed did not express that they are being neglected. Regarding the allegation " residents had severe UTI ”, it is alleged that R4, R5 and R6 had UTI. Staff interviewed stated that residents do get UTI, but it is not due to neglect. They stated all residents that need diaper change receive incontinence assistance every 2 hours or as needed and staff are trained to properly cleaned the residents to avoid UTI. Residents interviewed did not express that they are being neglected. Regarding the allegation " staff did not seek medical attention for residents ” , it is alleged tha t R3's tube (unsure type of tube) that was attached to R3's stomach looked infected. Complainant did not provide a last name for R3. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. Residents interviewed could not corroborate the allegation. (Continued to LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation "staff did not follow prescribed meals for residents”, it is alleged that R3 was on mechanical soft food diet, but staff kept feeding R3 regular food. Complainant did not provide a last name for R3. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. Staff interviewed denied the allegation stated that they follow a list that is on the kitchen that has all the residents with modified/prescribed diets. Residents interviewed could not corroborate the allegation. LPA observed the list for modified/prescribed diets in the kitchen. Regarding the allegation "staff did not report incidents to CCL” and "staff did not document residents falls", it is alleged that a resident had a fall and it was not documented or reported to Community Care Licensing (CCL). There is no records of this resident having a fall and staff could not remember if this resident had a fall either. Staff stated that the procedure regarding falls is as follows: contact the med-techs to come and assess the resident, write a report and submit it to supervisor. S1 is in charge of completing the licensing incident report and submitting it to the Executive Director for signature and the Executive Director submits it to CCL. 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, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided

The investigation revealed the following: Regarding the allegation "staff did not follow COVID protocol”, it is alleged that staff failed to follow COVID-19 guidelines. Staff interviewed denied the allegation and stated that full PPE supplies were used when there was a COVID-19 positive case. Residents interviewed could not corroborate the allegation. Regarding the allegation "staff did not aid residents with incontinence needs”, it is alleged that staff were not changing the diaper for R1, R4, and R5. Staff interviewed denied the allegation. They stated all residents that need diaper change receive incontinence assistance every 2 hours or as needed. Even if the resident has COVID-19 the staff are expected to wear full PPE supplies and provide the incontinence assistance. Residents interviewed could not corroborate the allegation. Regarding the allegation "staff did not observe change in residents condition”, it is alleged that staff did not check on R1 for 6-7 hours. Staff interviewed denied the allegation. They stated that R1 was severely ill and was placed on "alert charting" which meant that staff had to check on R1 every hour and complete a chart behind the resident's bedroom door. Residents interviewed could not corroborate the allegation. Regarding the allegation "staff did not feed bedridden residents”, it is alleged that staff did not feed R1 and R2 because R1 had COVID-19 and staff did not want to get near R1 and R2 would eat slow so the staff would get impatient. Staff interviewed denied the allegation. They stated that all residents are provided food and assisted with eating if the resident needs assistance. If a resident has COVID-19 then the staff are expected to wear full PPE supplies and assist the residents with feeding. Residents interviewed could not corroborate the allegation. Regarding the allegation "staff did not aid residents with hygiene needs”, it is alleged that staff did not shower R4. Staff interviewed denied the allegation. They stated all residents receive shower assistance up to 2-3 times a week or as needed. LPA reviewed the shower schedule and observed all residents name listed 2-3 times throughout the week. Residents interviewed could not corroborate the allegation. 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, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided