Atria Santa Clarita

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit regarding an incident report submitted to Licensing concerning Resident #1 (R1) being observed leaving the facility unassisted. According to the incident report, staff observed R1 walking on the sidewalk outside of the community. Staff escorted R1 back to the facility. The report further stated that R1 exited the facility through the back gate and was not immediately observed by staff. During today’s visit, LPA met with Resident Care Director Venca Avivi, who confirmed that R1 left the facility. Venca reported that R1 is physically capable of leaving the facility; however, per physician’s orders, R1 is not permitted to leave unassisted due to physical limitations, not cognitive impairment. Venca stated that R1 was taken to urgent care by R1’s daughter and was diagnosed with a urinary tract infection (UTI), which may have contributed to the incident. Facility staff reported there are currently no concerns regarding R1. The facility will continue to monitor R1 closely and document any changes in condition. LPA obtained and reviewed R1’s current physician’s report. At this time, no further review is required. During the visit, LPA also identified concerns regarding the facility Administrator on record, Eden Tolentino. According to Eden, her designated back-up Administrator is Chad Jones, who resides in Kentucky when Eden is not present at the facility. LPA spoke with Eden via telephone. Eden reported she has not been physically present at the facility since January 05, 2026, and stated that Chad Jones has been present full time. ( See LIC809C) 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 requested submission of an updated LIC 308 (Designation of Administrative Responsibility) and LIC 501 (Personnel Report), reflecting the days and hours the Administrator is working at the facility. At this time, there is no full-time Administrator physically present at the facility. Eden reported she is fulfilling the Administrator licensing requirements. LPA will follow up with Eden and Chad regarding the requested documentation. An exit interview was conducted, and a copy of this report was provided to Venca Avivi.

A review of the Admissions Agreement states , “…we will reassess your needs to determine whether your condition has changed, work with you to update your service plan, if necessary, and review it with you”. During interviews, staff stated facility will meet with R1 or their responsible party on 01/08/2026 to discuss the details and changes in the level of care and the increased fees associated with such changes. Based on interviews and record review, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.

The complaint alleged that R1 expired after sustaining a serious injury due to the fall while in care. According to the IB investigation, fire department records confirmed that on 12/06/2024, staff called 911 to request medical assistance for R1, who sustained a fall while being assisted in the bathroom. Staff interviews indicated they followed facility protocols for falls, including assessing R1, requesting medical attention, and monitoring R1 until emergency services arrived. On December 6, 2024, R1 was admitted to the hospital and diagnosed with a displaced distal femur fracture from a mechanical ground-level fall, which required surgery. R1 was discharged from the hospital on December 17, 2024, in stable condition and transferred to a skilled nursing facility (SNF). IB Investigator Torre’s review of R1’s death certificate indicated that R1 expired on January 22, 2025, while under care at the SNF. The immediate cause of death was listed as cardiopulmonary arrest (within minutes), with contributing conditions of Alzheimer’s dementia (within years) and cancer. Based on the investigation conducted by the IB Investigator and review of the medical records, there is insufficient evidence to support the allegation that R1’s death was the result of a serious injury sustained while in care at the facility. Therefore, the allegation “Questionable Death” is deemed Unsubstantiated at this time.

Over time, however, R1’s health declined, and R1 became a fall risk. Facility staff appropriately documented this decline and implemented preventative measures in collaboration with R1’s medical providers. Based on the available documentation and lack of corroborating evidence, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided to Executive Director.

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced annual inspection. LPA was greeted by front the receptionist. Executive Director (ED) April Princesa was not present during the initial inspection, but came shortly after. The entire facility has (3) floors, which is licensed for (160) non-ambulatory, of which (67) may be bedridden on the 1 st and 2 nd floor of villas 1 & 2. There is a hospice waiver for (13), and fire clearance approved for delayed egress for the Memory Care, located in villa 2. The current census is 123. Facility license/sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, rights of resident council, discrimination notice, theft and loss policy, activity schedule, and evacuation plan visibly posted. Common areas: The first floor, identified the front entrance lounge with a hospitality station that serves coffee, water, and tea. The Administration offices, beauty salon, resident’s rooms, and laundry were also observed. All areas were clean and appropriately furnished for resident’s comfort. Passageways were free from obstruction, and inside temperature was comfortable. The second and third floor consists of resident rooms, dining room, activity, fitness, snack room, mail room, and personal laundry equipment for residents. The third floor also has movie and game room, and library. Dining Room: Passageways were free from obstruction, with adequate lighting. There is a daily menu placed on the table, with chairs and table were comfortable and clean. LPA observed residents eating a variety and healthy food for lunch. Coffee, tea, and water is available throughout the day, as well as a variety of snacks. Resident Rooms : All apartments are provided with a microwave and refrigerator purchased by the facility. Rooms, floors, walls, and carpet areas were clean in good repair. Residents are allowed pets. Inside temperature was cool, and each resident has there own thermostat to regulate. Bathrooms: All were clean, with grab bars, non-skid mats, and shower chairs. There are emergency pull cords located by the toilet for emergency purposes. Residents also have emergency pendants. Due to time constraints, the annual was not able to be completed. LPA will continue inspection at another date and time; reviewing staff, resident, training and medication records and the memory care unit. Exit interview and copy of report provided to ED.

Therefore, based on documentation and interviews, the allegation is Unsubstantiated at this time. Allegation # 2: It was alleged staff failed to provide resident's authorized representative with incident reports. During the initial investigation, on June 06/07/2023, from 1130am to 2pm, LPA conducted interviews and obtained resident records, as well reviewed facility documents. During today’s visit, from 930am to 230pm, LPA conducted additional interviews and re-reviewed documents. It was reported to LPA by the family, that they requested incident reports of (R1) falling at the facility. LPA interviewed staff, who denied there was a request of any documentation for (R1). It was revealed to LPA, that the former Life Guidance Director was no longer working at the facility, and the request could have been directed to her. The family could not specifically identify who they requested the documents to. Therefore, based on interviews, LPA does not have enough evidence to prove the allegation, and it’s Unsubstantiated at this time. Exit interview and copy of report provided.

Regarding the allegation: Staff are illegally evicting resident: it’s being alleged that R1 was given a 30-day notice to pay or quit due to failure to pay their rent since January, 2023. LPA Spaeth received a copy of the 30-day notice to pay or quit letter issued to R1 on 5/04/2023. The letter clearly stated R1’s account is past due in the amount of $25,833.95, which represents a past due balance for the months of January through May, 2023. LPA Spaeth interviewed R1 on 5/30/2023 at 11:00 am who stated they did not remember receiving an eviction notice and could not remember if they were up to date with their payments. LPA Spaeth interviewed R1 today, 8/16/2024 at 11:00 am who stated they have made all their payments to the facility. LPA Spaeth spoke to the Business Director, Wendy Rose on 8/12/2024 at 4:00 pm who stated R1 has made all their outstanding payments. Based upon interviews and record review, the allegation is unsubstantiated . Regarding the allegation: Staff obtained & billed a resident for services not agreed upon: it’s being alleged that the facility told R1 they require supervision when leaving the facility and there would be a monthly additional charge. It’s also being alleged R1 was given a letter stating R1 requires this service and there would be an additional monthly charge for the service each month. LPA reviewed R1’s Admissions Agreement. R1 moved into the facility as of July, 2022. The Admissions Agreement states “Assessment of Your Needs which states a rate change will occur when the change in service occurs due to a resident’s need for a service change. Facility will then review the assessment with the resident.” LPA Spaeth reviewed the physician’s report (LIC 605C) which reveals R1 will need assistance when leaving the facility. LPA interviewed the Resident Services Director (S1) who stated they conducted the yearly assessment for R1 and reviewed the assessment with R1 each year. S1 confirmed R1 was aware they needed assistance when leaving the facility and also told R1 the charge would be indicated on their bill as a “private duty personnel” charge. LPA Spaeth spoke to R1 at 11:00 am who stated they were aware they would be charged for staff assistance when they left the facility. LPA Spaeth interviewed R2 – R10 who confirmed they have never been charged for services they have not agreed upon. Based upon record review, staff and residents’ interviews, the allegation is unsubstantiated . Continued on 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 Regarding the allegation: Staff did not provide requested records to resident's authorized representative. It’s being alleged that a resident's authorized representative requested copies of the resident’s records and did not receive them. LPA Spaeth was informed the records requested have been received by the requester. Therefore, the allegation is unsubstantiated . Exit interview conducted and a copy of the report was given.

Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility at 9:30am to conduct Annual inspection. LPA was greeted by front the receptionist, who notified the Executive Director (ED) April Princesa, and who was informed the reason of the visit. The entire facility has (3) floors, which is licensed for (160) non-ambulatory, of which (67) may be bedridden on the 1 st and 2 nd floor of villas 1 & 2. There is a hospice waiver for (13), and fire clearance approved for delayed egress for the Memory Care, located in villa 2. The current census is 132. Facility license/sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, rights of resident council, discrimination notice, theft and loss policy, activity schedule, and evacuation plan visibly posted. Common areas: LPA conducted a physical plant tour with (ED) April, and inspected the first floor, which identifies front entrance lounge with a hospitality station with coffee, water, and tea. The Administration offices, beauty salon, resident’s rooms, and laundry were also observed. All areas were clean and appropriately furnished for resident’s comfort. Passageways were free from obstruction, and inside temperature was comfortable. The second and third floor consists of resident rooms, activity, fitness, snack room, mail room, and personal laundry equipment for residents. The third floor also has movie and game room, and library. Dining Room: Passageways were free from obstruction, with adequate lighting. There is a daily menu placed on the table, with chairs and table were comfortable and clean. LPA observed residents eating a variety and healthy food for lunch. Coffee, tea, and water is available throughout the day, as well as a variety of snacks. Resident Rooms : All apartments are provided with a microwave and refrigerator purchased by the facility. Rooms, floors, walls, and carpet areas were clean in good repair. Residents can have pets, and during inspection, LPA observed cats and dogs signs posted on resident's doors. Thermostat, smoke alarms, and carbon monoxide detectors were being tested during the inspection, hired by Johnson Control Inc, (JCI) company. 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 Bathrooms: All were clean, with grab bars, non-skid mats, and shower chairs. There are emergency pull cords located by the toilet for emergency purposes. Residents also have emergency pendants. Water temperature was measured in several of the rooms. Memory Care Unit : Is located adjacent to the Assisted Living facility. It has (3) floors, with a delayed egress front door and keypad lock located outside the facility. The current census is (38). Rooms are either private or separated, with (1) shared bathroom. All common areas were clean and in good repair. Passageways were free from obstruction, and furnishings were appropriate for residents. There is a dining room, kitchen, and activity room for resident’s entertainment and comfort. Snacks, water, and tea are available throughout the day. Meals are prepared by the main kitchen and delivered to the unit. Smoke alarm and carbon monoxide detectors are in each resident room. . Record Review : Medication room was locked and inaccessible to residents. There is a complete first aid kit at the facility. Residents and staff records were reviewed. LPA reviewed files of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed. Residents files appear to be complete and updated. Staff present files were also reviewed, staff files appear to be complete and updated training is computerized. First aid and medication training current. No health and safety hazards noted during the visit. **Note, inspection tool questions for staff and residents did not populate and LPA was not able to complete them. Exit interview conducted and copy of report provided to Administrator.

(continued from LIC 9099) During the course of the investigation, Investigator Spindola interviewed the Assistant Administrator, staff and family member on different dates and time from 05/13/21 to 07/17/21. IB Investigator Spindola also reviewed Hospital Records on 05/24/21 and 07/07/21 and Los Angeles Sheriff Department (LASD)’s record on 07/09/21. Regarding the allegation that lack of care and supervision resulting to dehydration, IB Spindola’s hospital record review on 05/24/21 revealed that during these hospitalization of R1 due to fall on 03/15/21 and 04/02/21 R1 was diagnosed by the hospital with Urinary Tract Infection (UTI) and again was diagnosed with UTI on 04/30/21 when hospitalized due to another fall. IB Investigator Spindola’s interview with staff on 05/17/21 revealed that R1 used to drink a lot of water before but since R1 declined, R1 had limited intake. LPA’s interview with three (3) care staff who used to care for R1 on 03/26/22, revealed R1 was regularly provided with liquids for hydration, including water, juice and/or soda during R1’s stay at the facility. Based on the information gathered during the course of the investigation, there is an insufficient information to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted and report issued.

(continued from LIC 9099) LPA's interview with the Resident Service Director today at around 1:00 PM, also revealed that they were not aware of the PCP's ordered evaluation until the evaluating doctor arrived at the facility. Regarding the allegation that resident sustained an injury from a fall while in care, it was alleged that R1 fell on the night of 10/20/19 and was rushed to the hospital for an emergency surgery for a broken hip. LPA's record review today between 10:00 AM to 1:00 PM revealed that R1 was assessed by a third party out of state nurse prior to move in on 07/19/19 and was assessed to be a minimal fall risk and was assessed by an out of state physician on 07/10/19 to be ambulatory but requires walker. Pre move in appraisal of the facility dated 07/30/19 also revealed that R1 requires only minimal fall assistance but was placed on status check every two (2) hours. This is consistent with Move in Assessment dated 08/21/19 and Thirty (30) day Assessment of R1 dated 09/19/19. LPA's interview with three (3) care staff who attended to R1 during R1 stay at the facility on 11/05/22 between 11:30 AM to 1:45 PM and two (2) care staff today between 1:00 PM to 2:30 PM revealed all five (5) of them do check R1 every two (2) hours as scheduled on their daily assignment to ensure that R1 was doing well. Based on the information gathered during this and prior visits, the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

During interviews with residents, they all stated that they do not feel that the facility is understaffed and that the response times for assistance are not long. Furthermore, LPA pushed resident #3's (R3) call button and observed that staff responded within three (03) minutes. During interviews with staff, they all stated that they do not feel the facility is understaffed, that no matter how busy the staff are, there is always someone available to assist residents and the average response times to the call buttons are between five (05) to ten (10) minutes. Based on interviews, record reviews and observations, there is not enough information to verify the allegation, therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.

Interviews with staff revealed that all hygiene needs are being met, that each resident has a shower schedule, are also showered more often if needed, and that caregivers are on standby for those who need assistance. Staff also stated that at times R1 refuses to shower and that they can only encourage R1 to shower but cannot force. During interviews with residents, they all stated (including R1) that their hygiene needs are being met and that they are being showered timely. During interviews with the RP, they stated that R1 was not being showered often enough, smelled at times, but they are also aware that R1 refuses to shower. During observations of residents, LPA found that they all appeared clean, well groomed and did not experience any malodor during the visit. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not provide appropriate incontinent care. It was alleged that resident #1 (R1) is not getting assistance with diapering. To investigate this allegation, on 09/06/2022 at 12:30 PM, LPA interviewed staff and residents and, on 10/06/2022 at 01:30 PM, LPA interviewed the Reporting Party (RP). In addition to the interviews, on 10/10/2022 at 12:30 PM, LPA conducted a physical inspection of randomly selected rooms. Interviews with staff revealed that all incontinent care needs are being met, they change R1’s diaper up to three times a day, but are changing R1 more often, if needed. Staff also stated R1 always requests for two diapers at a time so that in the event they soil one, they may rip it off, discard it, and pull up the clean one. During interviews with the RP, they stated that the facility is not checking on R1 frequently enough and they are not changing the diaper as often as they should. During interviews with residents, they all stated (including R1) that their toileting needs are being met timely. Furthermore, LPA observed residents and found that they all appeared clean and did not see or smell any bodily fluids or waste during the visit. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Cont. on 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 --- Staff issued an improper eviction notice to resident. It was alleged that resident #1 (R1) was issued an eviction notice. To investigate this allegation, on 09/06/2022 at 12:30 PM, LPA interviewed staff and residents, on 09/06/2022 at 2:30PM, LPA requested pertinent documents and, on 10/06/2022 at 01:30 PM, LPA interviewed the Reporting Party (RP) and requested documents. Interviews with staff revealed that R1 was not issued an eviction notice. During interviews with the RP, they stated that, because they did not agree with certain charges, the facility issued an eviction notice. LPA asked RP to produce this eviction notice but they did not provide one. During interviews with residents, they all stated (including R1) that they have either never been issued an eviction notice or did not know whether they ever have been. Record reviews also confirmed that R1 was not issued an eviction notice. However, according to what was found in the R1’s file and what was provided by the RP, the responsible party failed to pay for a portion of the bill (for higher level of care) and it stated that failure to pay may lead to a termination of services “including potential eviction procedures” and on a different letter for an attempt to collect a debt it stated, if payment is not received “we have no choice but to terminate the Residency Agreement and commence eviction.” Based on interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was provided to the Executive Director, whose signature on this form confirm receipt of these documents.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit to the facility. LPA arrived at 11:00 AM. Upon entry, LPA met with the Executive Director, Johnny Ortiz, and screened for COVID 19. LPA conducted a physical plant tour at 11:30 AM. An SOC341 was received 08/02/2022 alleging that staff #1 (S1) grabbed and pulled resident #1 (R1) by the arm and wrist to re-direct the R1. Later that day, R1 complained about soreness at the site of where R1 was allegedly grabbed. On 08/08/2022, from 12:30 PM - 3:00 PM, LPA interviewed three staff and one resident. No action was taken during the visit. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.

It was also reported that the R1’s diaper is changed at least three time per day and more if needed. On 04/20/2022 at around 4:00pm, LPA interviewed Med Tech Miriam Zepeda Aguilar. Interviews revealed that R1’s gauze is changed by home health twice a week and that the facility wraps gauze around the open wound as needed. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility did not communicate with authorized representative about change of services being provided. It was alleged that the Responsible Party did not have any knowledge of the change in level of care. To investigate this allegation, on 03/16/2022 at 10:15am, LPA interviewed staff and requested records. On 04/20/2022 at around 5:00PM LPA interviewed the complainant. Interviews and record review revealed that an assessment was completed, the facility did notify the resident prior to the change in the level of care and the Admission Agreement, which was signed by all parties, clearly states, “…when the assessment of your needs indicates that the level of care we are providing you is not appropriate for your needs, we may change your level of care and the fees that we charge you. Any such change in fees due us resulting from a change in the level of care will be effective immediately and we will notify you or the Responsible Party of the change”. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility is in disrepair. It was alleged that R1’s room had a leak from the room above and as current R1's ceiling is peeling and has not been repaired. To investigate this allegation, on 03/16/2022 at 10:15am, LPA interviewed staff and on 04/20/2022 at 3:30pm, LPA conducted a physical inspection of randomly selected rooms including R1’s room. Interviews revealed that one day the tenant in the room above R1’s room left the sink running and that the water was leaking below, but that it was soaked up immediately and there were no damages. During the physical inspection, LPA did not observe any disrepair in any of the rooms, including R1’s room. (Cont. 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 LPA asked the Reporting Party about the disrepair and they were unable to identify any problems or where the alleged previous problems were. The room was neat and clean, there was no sign of water damage, cracking, paint chipping or molding. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Interviews revealed that staff notified R1’s physician about the loss of appetite, decreased fluid intake and loose stool and that the physician’s response was, “no update in medications or care needed at this time”. Subsequently, Staff #1 (S1) was notified of R1’s rapid decline and immediately called 911. Based on the interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility has C diff contamination. It was alleged that R1 got the infection from staff or other residents and since residents share bathrooms, it is highly likely that the facility has more cases of C diff. To investigate this allegation on 04/06/2022 LPA conducted a physical plant tour at 10:00 AM, interviewed staff and requested pertinent documents from 11:00 AM - 2:20 PM. Interviews, record review and observations revealed that there were no other cases of C diff during R1’s time at the facility. LPA observed R1’s room and R2’s room, whom which R1 shared a restroom with. Record reviews revealed that R2 did not have C diff before or after R1 was admitted. Record reviews and interviews further revealed that neither staff nor residents contracted C diff during R1’s time at the facility. Based on the interviews, record reviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.

Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was provided to the Executive Director, whose signature on this form confirm receipt of these documents.

(continued from LIC 9099) Regarding the allegation that Staff did not safeguard resident's personal belongings, it was alleged that R1's eye glasses were lost. LPA's interview with Staff #1 (S1) on 03/26/22 between 10:00 AM to 2:00 PM revealed that the primary care staff of R1 reported that the R1's eye glasses broke when R1 had an unwitnessed fall on 03/15/21. LPA's interview with the Memory Care Director today at around 11:30 AM today, however, revealed that she did not receive any report about R1's broken eye glasses otherwise she should have reported it to the family member to have it replaced as it was a prescription eye glass. Based on the information gathered during this and prior visits, there is insufficient information to support the allegation and therefore deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

During the physical plant inspection, LPAs observed the thermostats at a comfortable range of 72 - 75 º. During the interviews it was reported that R1 bundles up layers of clothing frequently and often feels cold. Based on the interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Resident was dehydrated. It was alleged that Resident #1 (R1) was . To investigate this allegation, on 03/11/2022 at 9:40 AM, Licensing Program Analysts (LPAs), Abeye Duguma and Gary Tan, conducted a physical plant tour and interviewed staff between 10:15 AM – 11:40 AM. Interviews and observations revealed that the resident drinks lots of water and always has a tumbler full of water in the room. LPAs also observed a note on the night stand that read, “drink your water”, a tumbler full of water next to the bed and resident, who was participating in group activities at the time, sitting with a cup full of water. Based on the interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Facility did not have hot water for a week. It was alleged that the facility did not have hot water for a week. To investigate this allegation, on 03/11/2022 at 9:40 AM, Licensing Program Analysts (LPAs), Abeye Duguma and Gary Tan, conducted a physical plant tour, requested pertinent documents and interviewed staff between 10:15 AM – 11:40 AM. Interviews revealed that the water heater’s ignitor pilot was reported broken on 02/28/2022, that a Work Order was submitted the same day and fixed within a weeks’ time. During the time that the water heater was not in working condition, the residents were transferred to the adjacent building for showering and other hygiene needs. In addition, LPAs selected rooms at random and it was observed that all faucets had hot water during the time of the visit. Based on interviews and observations, the facility was able to maintain the health, hygiene needs and safety of their resident through alternate means. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.

(continued from LIC 9099) Regarding the allegation that the residents' room was dirty, it was alleged that the room was filthy and had sticky floors and dusty. During today's visit at around 11:00 AM, LPA inspected five (5) random rooms on the first floor, six (6) random rooms on the second floor and nine (9) random rooms on the third floor of the Memory Care building and did not observe any filth, dust or sticky floors on all of the rooms inspected. LPA Valenzuela's physical plant tour conducted on 05/11/21 at 11:15 AM, where in she inspected a total of twenty one (21) random rooms on all floor, also revealed that the facility was clean and in good condition. Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

--- Residents door is in disrepair It was reported that the resident's door is in disrepair. To investigate these allegations, on 03/11/2022, between 12:30pm - 2:30pm LPAs conducted interviews and requested pertinent documents. The interviews with facility staff revealed that the resident would often aggressively handle the door, motioning the door handle up and down beyond its intended design limitations and it eventually broke. The pertinent documents reviewed by the LPAs and interviews with facility staff also revealed that a work order was place for repairs on 03/08/2021 at 12:43pm and the door was repaired the following day. Based on the information gather, during this and prior investigations, the allegation is unsubstantiated at this time.

--Facility did not provide resident with a 60day notice of rent increase for COVID expenses. It was reported that R1 and responsible party was given a notice three weeks ago for rent increase of $500 for COVID expenses starting February 1, 2022. To investigate this allegation, on 02/02/2022 at 12:00pm LPA spoke to facility staff and requested pertinent documents. Interview and record review revealed that the facility notified R1 and responsible party more than sixty (60) days prior to the increase. The notice was sent October 28, 2021 with an increase in rent /fees effective January 01,2022. Based on interviews record review, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --Resident's closet door is in disrepair It was reported that resident’s closet door is broken and only one side opens. To investigate this allegation, on 01/24/2022 at 10:30am LPA spoke to other parties and it was reported that the wooden closet in R1’s room was off its track. The report was supplemented with images that were captured during the other party’s visit to the facility. During the investigation conducted on 01/24/2022 at 11:00am, LPA randomly selected residents’ rooms to inspect and all closet doors were in working order. On 02/02/2022 at 12:15pm, LPA interviewed staff and it was reported resident failed to report the disrepair and that upon discovery, the maintenance crew was informed, and the closet door was placed back on its track with minimal delay. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--Staff did not provide adequate laundry service for resident It was reported that resident’s laundry hadn’t been done in two weeks because the same clothes were in it. To investigate these allegations, on 01/24/2022 at 11:10am LPA spoke to facility staff and residents. Interviews revealed that laundry is done a minimum once per week. During the investigation conducted on 01/24/2022 at 11:30am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. LPA discovered that each resident has a separate laundry basket and none were full and the residents had plenty of clean linen and clothes. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --Resident's room is dirty. It was reported that resident’s room is not being dusted and cleaned and that there were dirty diapers mixed with clean clothes. To investigate these allegations, on 01/24/2022 at 11:10am LPA spoke to facility staff including housekeepers. Interviews indicated that the room is being picked up daily as needed, deeply cleaned and dusted once a week. During the investigation conducted on 01/24/2022 at 11:30am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. The floors appeared to be clean and free from hazard. All inspected rooms were neat and clean with minimal dust. All closets and drawers were checked for cleanliness, nothing soiled was found and everything appeared to be well maintained. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --Staff are not properly dressing resident It was reported that R1 was in a robe that did not belong to R1. To investigate these allegations, on 01/24/2022 at 11:10am LPA spoke to facility staff and residents. The residents were all asked if they felt that they were missing any belongings and they all replied, “no”. Interviews revealed that laundry is done a minimum once per week. During the investigation conducted on 01/24/2022 at 11:30am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. LPA discovered that each resident has a separate laundry basket of which none were full, the residents had plenty of clean linen and clothes. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (CONT. on LIC9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 --Staff did not provide resident with adequate amounts of water. It was reported that resident is not been given water. To investigate these allegations, on 01/24/2022 at 11:10am LPA spoke to facility staff and residents. The residents were all asked if they felt that they were getting enough food and water and those that were able to all replied, “yes”. Interviews revealed that staff encourage food and water intake. During the investigation conducted on 01/24/2022 at 11:30am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. LPA discovered that residents had water in their rooms. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Licensing Program Analyst (LPA) Abeye Duguma met with Venca Avivi, Nurse for a One (1) Year Required - Infection Control visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:00am and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and throughout the facility. The facility has a designated outdoor visitors' area located in the courtyard. The facility has sufficient stock of PPE in a storage room located in the nurse’s office and storage. The facility has a total of one hundred thirty-four (134) bedrooms of which thirty-nine (39) are in the memory care (MC) building. There are ninety-five (95) bedrooms in the main building, each with its own bathroom and of the thirty-nine (39) bedrooms in MC, thirty (30) are Jack and Jill (one bathroom for every two bedrooms) and ten (10) bedrooms have their own bathroom, eleven (11) public restrooms for both residents and staff and one (01) staff only restroom. The facility is fire cleared for one hundred sixty (160) non-ambulatory of which sixty-seven (67) may be bedridden and a hospice waiver for ten (10). The facility is currently occupying one hundred thirteen (113) residents of which seventy-nine (79) are non-ambulatory and six (06) are in hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins are stored in the laundry room and in a locked cleaning supplies room. Food Service/Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days (continued on LIC 809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a drawer inaccessible to residents. Living/common and dining room furniture were also checked. The living/common room is neat and clean along with the dining room. The facility maintains a comfortable temperature between 73-76°F throughout. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located throughout the facility, observed to be full and last inspected on 11/15/2021. The clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by both themselves and the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 115.3°F. Towels and washcloths are not shared. There was enough clean linen available in the residents' rooms. LPA observed medication to be locked in a mobile cabinet and inaccessible to residents, located in the Med Tech room. There is also a complete first aid kit located in the nurse’s office. Exit interview conducted. Copy of this report issued.

--- Staff did not ensure that resident's room was free of hazards. It was alleged that Staff did not ensure that resident's room was free of hazards. To investigate these allegations, on 10/26/2021 at 11:10am LPA spoke to facility staff. Interviews indicated that the resident’s room is cleaned daily by staff and the housekeeper deep cleans weekly. During the investigation conducted on 10/26/2021 at 11:15am the resident’s room was inspected by the LPA and the room appeared to be clean at the time of the visit. During a subsequent complaint investigation visit conducted on 11/17/2021 at 11:30am the resident’s room was again inspected by the LPA and the room appeared to be clean and free from hazard at the time of the visit. Staff also reported that they remove any hazardous items from the room when discovered. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The broken frame was stored with R1’s personal items and staff had no knowledge of it. A broken picture frame was discovered by R1’s family member who came to visit R1. On 10/26/2021 @ 11:00am LPA Duguma inspected the room and noted that the picture frame was previously stored in a place that may not be checked by the care staff. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --Resident's room is not being cleaned . It was reported that resident’s room is not being cleaned. The floor in R1’s room is sticky. To investigate these allegations, on 10/26/2021 at 11:10am LPA spoke to facility staff including housekeepers. Interviews indicated that the room is being picked up daily as needed and deeply cleaned once a week. During the investigation conducted on 10/26/2021 at 11:00am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. The floors appeared to be clean and free from hazard. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Resident's hygiene needs are not being met. It was alleged that R1’s teeth were not brushed for a few days. To investigate these allegations, on 10/26/2021 at 11:30am LPA spoke to facility staff. Interviews indicated that the resident is assisted with teeth brushing and other hygiene related daily functions. During investigation conducted on 11/17/2021 @ 11:45am the resident was inspected by the LPA and the resident appeared to be clean and well-groomed. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Please see continuation page)