Belmont Village Encino.

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 12:29PM for a required one-year visit. The LPA met with the Executive Director (ED) Lance Shenk. Entrance interview conducted. At 12:40PM, the LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 102.9 degrees F and 111.6 degrees F. COMMON AREAS: The facility has five (5) total floors, one (1) being the garage/basement. The basement provided general parking, contained emergency food and water, and general storage as well as extra facility supplies/emergency supplies. On the first floor, there was the concierge desk, the great room, common restrooms, bistro, bistro patio, staff lockers, dining room, courtyard, kitchen, and memory care unit. Report 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 The memory care unit contained resident units, common restrooms, a courtyard, laundry room, and office. On the second floor, there was a wellness center, resident units, town hall room, activity room, balcony, and common restrooms. On the third floor, there was a beauty salon, resident units, discovery room, gym, card room, laundry room, and common restrooms. On the fourth floor, there was a laundry room, resident units, terrace rooftop, office, and common restrooms. LPA Huynh observed common areas to be clean, clear of obstructions/hazards, and furniture was in good condition with patios/courtyards providing shade for residents. Required postings were found in the hallway on the first floor. There were no bodies of water observed during today’s visit. KITCHEN: The main kitchen is located on the first floor, attached to the main dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. There was a sufficient supply of perishable and non-perishable food. The LPA observed the walk-in refrigerator and freezer; food appeared to be of good quality and labeled with expiration dates. Kitchen sinks had signage of tap water delivering above 125 degrees F. INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. There were fire extinguishers throughout the facility, which were serviced on 09/26/2025. The fire alarm system is tested annually with the last inspection on 07/08/2025 by Absolute Fire Protection, INC. Emergency disaster drills are conducted as required with the last drill on 5/14/2026. Due to time constraints, the LPA will return at a later date to continue the annual. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit after the facility self-reported an alleged sexual assault. The LPA arrived at 9:43AM and met with Executive Director (ED) Abigail Traxler. Entrance interview conducted. On 01/27/2026, the Department received a notification of an alleged staff on resident sexual assault that reportedly occurred a week prior. During today’s visit, the LPA and ED conducted a physical plant tour at 9:53AM and no immediate concerns were observed. Beginning at 12:25PM, the LPA reviewed and obtained pertinent documents including the SOC 341 and Incident Report. The ED was advised that the case was referred to the Investigations Branch (IB). The LPA determined that further investigation is needed. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

Allegation: “Staff did not ensure resident's hygiene needs were being met” It was reported that resident hygiene needs such as washing hands were not maintained which resulted in Resident #1 (R1) contracting Clostridioides Difficile (C. Diff). Interview with residents revealed no overall concerns about the facility’s cleaning protocols. Residents stated they frequently observe staff cleaning/sanitizing their rooms in addition to common areas. Residents also had no concerns regarding their hygiene needs and expressed that they always feel clean. Residents reported washing their hands as frequently as they can with staff assistance. Staff reported that residents with illnesses or contagious diseases are kept in isolation in their rooms or sent to the hospital. During this time, personal protective equipment (PPE) is provided outside the rooms for staff utilization when providing care. As an extra precaution, typically one (1) staff is assigned to that resident’s care to prevent further contamination. Residents who are symptom free and cleared of their illness will then return to the community and staff then clean the infected rooms which include laundry services and sanitizing/disinfecting all surfaces. During day-to-day operations, the facility’s common areas are cleaned frequently with staff access to cleaning chemicals if needed. Housekeepers and the maintenance team provide deep cleanings during the overnight shifts. Staff reported hand sanitizing stations throughout the facility for everyone to use in addition to following hand washing and glove precautions. Specifically, the MCU utilizes hand wipes before meals to accommodate resident preferences. Record review revealed that R1 experienced a change of condition on 08/29/2024 and was subsequently transferred to the hospital. On 08/31/2024, R1 returned to the facility with an eye infection and was prescribed antibiotics. R1 later tested positive for C. Diff on 09/02/2024, was sent to the hospital, and returned to the facility on 09/17/2024 with negative results. On 10/01/2024, R1 showed symptoms of C. Diff, was transferred to the hospital, and returned to the facility on 10/11/2024. Medication review revealed that R1 was not prescribed antibiotics in August 2024; however, in September 2024 R1 took three (3) antibiotics and two (2) antibiotics in October 2024. Report Continued 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 It was also revealed that Resident #2 (R2) had C. Diff in March 2024 and was sent to the hospital until asymptomatic and returned to the facility and has not had C. Diff since. Furthermore, R1 moved to the MCU from Assisted Living in December 2023, and R2 moved to the MCU from Assisted Living on 02/19/2025. Although it was possible both residents may have been in contact at community events, R1 and R2 were not in contact while actively diagnosed with C. Diff. Per information released by the U. S. Centers for Disease Control and Prevention (CDC) on 12/18/2024, C. Diff is common among individuals in healthcare settings such as hospitals and nursing homes. It is spread from person to person through feces and inactive spores in the environment that can be activated by swallowing the spores. The CDC reported C. Diff infections can also occur when taking antibiotics which result in C. Diff side effects. It was recommended to reduce the spread by washing hands with soap and water after restroom use and before meals. Based on interviews and record review, the facility followed infection control procedures and ensured residents’ hygiene were maintained. Additionally, R1 visited the hospital and was prescribed antibiotics shortly before contracting C. Diff, which may have increased their risk of exposure. Although R1 did contract C. Diff, there is not sufficient evidence to prove the alleged violation was a result of resident hygiene needs being unmet, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

During today’s visit, the LPA and ACDs conducted a physical plant tour at 1:40PM and no immediate concerns were observed. The following was then determined: Allegation: “Due to staff negligence, resident fell resulting in an injury” It was reported that Resident #1 (R1), a known fall risk, sustained a fall on 06/18/2025 that resulted in a sprained ankle due to staff negligence. Interviews with five (5) residents revealed that falls do not often occur in the MCU and that staff are consistently nearby to provide assistance. Residents reported utilizing assistive devices such as walkers and wheelchairs to prevent falls and stated that staff respond immediately and appropriately if a fall does occur. Staff interviews revealed that fall prevention protocols included motion censored floor and bed mats, bed rails, fall detection cameras in each resident room, and monitoring for behavioral changes. Staff reported that falls in the MCU are infrequent and, when they do occur, they are often “staff assisted,” meaning staff guide residents safely to the floor. Unwitnessed falls reportedly occur on average zero (0) to one (1) time per month. Staff stated that fall procedures include notifying all staff via radio, ensuring the resident is safe, and placing a pillow under the resident’s head. The med-tech and LVN (nurse) then assess the resident’s condition, including range of motion and pain. The LVN also reviews fall detection footage to confirm the fall and determine whether the resident may have hit their head and then decides if hospital transport is necessary and notifies the resident’s family and hospice agency. Staff reported that R1 was initially capable of independently ambulating and required minimal staff assistance with activities of daily living (ADLs). Over time, R1’s condition declined and R1 required assistance with all ADLs. R1 was considered a fall risk when ambulating due to unsteady, shuffling, and twisting feet and required arm support for balance. Staff preferred utilizing R1’s wheelchair for transfers and escorts and reported that R1 received physical therapy (PT). Staff stated they expressed safety concerns to R1’s family; however, the family insisted that staff continue assisting R1 with walking. Report Continued 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 observed family-hired private caregivers assisting R1 with walking and noted instances where R1 appeared to be dragged, prompting staff to intervene. The MCU director stated the facility does not provide two (2) person walking assistance, as this indicates unsafe ambulation. Staff also reported that following R1’s fall, the facility conducted additional in-service training on fall prevention. On 06/18/2025, R1 sustained a fall in their room while Staff #1 (S1) assisted with R1’s morning ADLs. S1 stated they intended to use R1’s wheelchair to escort R1 to the restroom; however, R1 showed signs of wanting to walk. S1 attempted to comply with the family’s request for assisted ambulation. S1 briefly let go of R1 to move the wheelchair out of the path, at which point R1 took several steps independently, lost balance, hit the wall, and fell. Fall detection footage showed S1 entering R1’s room at 7:45AM and providing assistance with ADLs including dressing and incontinence care. S1 positioned R1’s wheelchair at the foot of the bed and walked R1 toward it for support while finishing with dressing. At 7:51:47AM, S1 assisted R1 in letting go of the wheelchair and took five (5) steps toward the hallway before turning to reposition the wheelchair. R1 continued walking independently, taking an additional five (5) steps before losing balance at 7:51:53AM. At this time, S1 turned back toward R1 and immediately rushed to R1. R1 fell leaning towards their left, hit the wall, and hit the floor. S1 notified staff and placed a pillow under R1’s head. The MCU med-tech arrived and conducted an initial assessment, followed by the LVN who completed a secondary assessment. At 7:57AM, R1 was placed in their wheelchair and S1 continued assisting with ADLs. R1’s Resident Appraisal dated 11/03/2023 indicated R1 was ambulatory without assistance. The Resident Assessment and Service Plan dated 07/03/2025 documented R1 to need hands-on assistance with showering, dressing, grooming, incontinence care, feeding, and transfer assistance by one (1) staff with escorts to and from meals and activities. It was also noted that R1 required increased room safety checks due to fall risk and was wheelchair bound. Report Continued 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 Physician Report dated 07/10/2025 indicated R1 was receiving hospice services for a diagnosis of end stage dementia, was non-ambulatory and required assistance with repositioning and transferring. Post-fall X-Rays on 06/21/2025 and 07/02/2025 ruled out fractures on R1’s spine, hips, and knees. A doctor’s visit summary on 07/18/2025, noted the family reported R1 was “walking with some assistance” prior to the fall. The physician assessed R1 as having diffuse sarcopenia and a left ankle sprain as a result from their fall. PT records documented services beginning 03/29/2024 through discharge on 07/21/2025. R1 received therapy to improve fine motor coordination, muscle strength, functional activity tolerance, and standing balance with the goal of independently performing ADLs. R1’s baseline on 09/01/2024 indicated the ability to maintain balance against moderate resistance for approximately ten (10) minutes with standby assist (supervision) for safe ambulation. Additionally, R1 demonstrated fine motor coordination with stand by assistance. On 05/22/2025, PT documented that R1 required maximum arm assistance for gait activities and maximum assistance with transfer. Service Logs recorded ten (10) PT visits post-fall. A PT assessment on 06/25/2025 indicated R1 had potential for improvement but progress was slower than expected. PT documented that R1 required skilled rehabilitation due to impairments including balance deficits, decreased body awareness, cognitive decline, decreased dynamic balance, reduced functional tolerance, decreased attention, strength impairments, pain, and postural alignment issues. Based on interview and record review, R1 was appropriately assessed as a fall risk, and staff were aware of and responsive to R1’s changing condition. Although R1 sustained a fall resulting in an ankle sprain, there is not sufficient evidence to prove the alleged violation was a result of staff negligence, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

Between 08/12/2025 and 09/29/2025, Investigator Sonia Torre conducted interviews with relevant parties including facility staff, residents, and family. Investigator Torre also obtained and reviewed additional documents including hospital and hospice records, law enforcement reports, and wound care records. During today’s visit, the LPA, ED, and Memory Care Unit Director conducted a brief physical plant tour at 10:35AM, and no immediate concerns were observed. The following was then determined: Allegation: “Due to staff neglect, a resident sustained an unstageable pressure injury while in care.” It was alleged that due to staff neglect, Resident #1 (R1) sustained an unstageable sacral pressure injury while residing at Belmont Village Encino. R1 had a diagnosis of dementia, hypothyroidism, and congestive heart failure with a documented history of motor impairment and skin breakdown and required assistance with activities of daily living. Facility Nurse Assessments noted R1 had dry skin in the sacral area, discoloration and bruising on the right extremity toe and anterior body, and an open sore on the front head area and redness on the sacral region. Home Health Records from 04/23/2025 to 05/21/2025 noted R1 received services for fungal skin infections and development of Stage II pressure injuries on the buttocks. Wound care was initiated for Stage II injuries on the right buttocks, right posterior upper thigh, and right medial upper thigh. On 05/17/2025, it was documented that the pressure injuries on the right lower buttocks and right upper thighs had healed and required no further care. Hospice Records from 05/22/2025 to 07/17/2025 revealed R1 received two (2) skilled nurse visits and three (3) aide visits per month. Wound care services were provided on 05/31/2025, 06/05/2025, 06/16/2025, 06/17/2025, 06/21/2025, and 06/23/2025. Report Continued 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 On 06/11/2025, R1 was documented to have four (4) Stage III pressure injuries: right posterior lower buttocks, left posterior lower buttocks, left posterior upper buttocks, and left posterior buttocks. On 07/16/2025, facility staff reported wound changes were observed with R1 experiencing increased pain. R1 was transferred to Encino Hospital Medical Center on 07/17/2025 for a higher level of care to address the progressing wounds. R1 was at high risk for further skin breakdown due to impaired nutritional status, limited mobility, multiple comorbidities, altered continence, and impaired skin integrity. Hospital records noted a pre-operative diagnosis of unstageable sacral pressure injury, later determined post-operatively to be Stage III. R1 was discharged to a Skilled Nursing Facility (SNF) on 07/24/2025. Interview with R1’s Responsible Person revealed that R1’s condition declined over the course of three (3) years and required full assistance except for feeding. They reported no concerns about the level of care R1 received and confirmed awareness of R1’s pressure injuries, which were treated through Hospice and wound care. R1 was observed to be repositioned throughout the day; despite this, R1’s wounds did not improve. Interview with four (4) staff confirmed R1’s declining condition and lack of wound improvement. Staff documented R1’s change of condition, notified their Supervisors and Hospice, and it was ultimately determined that R1 required a higher level of care than Hospice could provide. Staff also noted R1 had chronic skin breakdown and eczema, contributing to further complications. Based on record review and interviews, while R1 did experience pressure injuries, there is insufficient evidence to determine that staff neglect caused or contributed to the unstageable sacral wounds. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Report Continued 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 Allegation: “Staff refused to accept resident back from hospital” It was alleged that the facility refused to accept R1 back from the hospital due to their wounds. R1 was transferred to the Hospital on 07/17/2025 and subsequently discharged to a SNF on 07/24/2025. Facility Administrators reported they were not notified by the hospital of R1’s transfer to the SNF. The Director of Nursing later observed R1’s name on a room assignment at the SNF during an unrelated visit and inquired about the transfer. Interview with R1’s Responsible Person confirmed R1 would temporarily reside at the SNF for wound care before returning to Belmont Village Encino. The Director of Nursing also confirmed that R1 would be accepted once wounds improved. During today’s visit, the LPA confirmed R1 returned to the facility. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegations: 1.) Staff pushed resident. 2.) Staff are violating resident’s personal rights. 3.) Staff threatened resident. 4.) Water temperature not within required range. On 05/09/2024, the Department received a complaint alleging Staff #1 (S1) and Staff #2 (S2) forcing Resident #1 (R1) into taking a shower in which the water was inconsistent going from scolding hot to ice cold. It was alleged that S1 and S2 threaten R1 and pushed R1 causing R1 to fall. During the initial visit, interview with R1 revealed little to no information regarding the allegations. R1 did not comment on the allegations and stated that there are no concerns regarding staff. R1 did state that R1 can control the shower’s temperature however that the shower controls can be difficult to navigate. Interview with ED conducted on 06/30/2025, revealed that R1 is no longer at the facility. The ED revealed that during the time of the alleged incident, the facility conducted an internal investigation in which both S1 and S2 denied the allegations. The ED stated that after their internal investigation, S1 and S2 were reassigned to work on different floors. The LPA conducted an interview with S1 during today’s visit; S1 denied the allegations. Residents interviewed did not voice any concerns regarding staff. Staff interviews revealed that they have not observed or heard of staff pushing residents or threatening residents. During the initial and subsequent visit, the LPA tested the water temperature throughout the building and found the water temperature to be within required range. The information obtained during the investigation did not include evidence sufficient to corroborate the 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 deemed Unsubstantiated at this time. Exit interview conducted with Courtney Barber . A copy of the report was provided.

Report Continued from LIC 9099. It was alleged that previous ED Ralph Balbin issued an eviction to Resident #1 (R1) without proper 30-days’ notice. Interviews with ED, responsible party of R1, and staff revealed that it was determined R1 had a change of condition requiring the resident to be placed in memory care to meet higher care needs. Facility management verbally informed R1 and responsible party of R1 on approximately 11/15/2022 that R1 will need to move to the memory care unit by 12/01/2022 or the facility will move forward with eviction proceedings on the basis that the facility is unable to meet the care needs of R1. Facility was notified by R1’s responsible party on 11/30/2022 that R1 will move out of the facility. R1 voluntarily moved out of the facility on 12/03/2022. No eviction notice was issued to R1 by the facility and no eviction notice was received by the Department for R1. Furthermore, R1’s admission agreement signed and dated on 12/30/2017 states the facility “upon thirty (30) day’s notice” may terminate the agreement if the facility “and the person who performs the reappraisal believe that the Community is no longer appropriate for [the resident]” and for “failure to comply with the general policies of the Community” which include possible termination if the resident/responsible party of resident “refuse to accept services required in order for [the facility] to meet [the resident’s] needs.” R1’s long-term physician confirmed R1’s change of condition in a signed letter dated 05/10/2022 stating that R1 “is dependent in in [their] basic and instrumental activities of daily living” (ADLs) and “is at risk for wandering and requires substantial supervision.” However, on 12/01/2022, R1 received a second opinion from their primary care provider who stated that they “support the decision of not moving the patient to Memory Unit at this time, given [the patient’s] current cognitive functional level.” On 11/26/2022, R1’s long-term psychologist also recommended that R1 “not go into Memory Care at Belmont Encino because it will be overly restrictive and insufficiently stimulating.” However, as no eviction notice was issued by the facility, the services required for the facility to meet R1’s care needs were refused, and a proper 30-day notice of moving was not provided, the information obtained through interview and record review for this investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation “Unlawful eviction” is deemed UNSUBSTANTIATED at this time. It was further alleged that facility staff financially abused R1 by overcharging for unused services and rent. LPA reviewed R1’s ledger from 01/01/2022 - 12/31/2023 and observed a monthly rent charge of $11,575.00 automatically charged to the card on file every 1 st day of the month and extra services charged every 15 th day of the month. Report Continued 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 Report Continued from LIC 9099-C. Additional charges were observed for services such as outings, haircuts, and escorts. R1 was charged $11,575.00 monthly rent on 12/01/2022 and was incorrectly automatically charged $129.56 on 12/15/2022 for multiple outings and an escort after moving; $17.93 outing, $41.63 outing, and $70 escort. R1’s ledger from 01/01/2023 documents that the extra services of $129.56 automatically charged after R1 moved out of the facility were returned to the account. A total of $11,829.56 ($129.56 of extra services not used + $125.00 recurring total incontinence management supplies (TIMs) fee automatically charged on 01/01/2023 + $11,575.00 monthly fee automatically charged on 01/01/2023) was returned to the account on 01/05/2023. On 01/15/2023, R1’s account was then credited a total of $10,770.41 ($115.07 TIMs fee + 10,655.34 monthly fee) for the period of 01/04/2023 – 01/31/2023, making the total balance $1,059.15 ($11,829.56 - 10,770.41). R1’s admission agreement signed and dated on 12/30/2017 states under “termination by resident” that a resident “may terminate this Agreement at any time, with or without cause, by giving the Executive Director thirty (30) days’ prior written notice of termination” and the resident “will continue to be responsible for [their] full Monthly Fee until the thirty (30) day period has expired.” The facility was notified by R1’s responsible party on 11/30/2022 that R1 will move out of the facility, meaning that the thirty (30) day period would be from 11/30/2022 – 12/30/2022. R1 moved out of the facility on 12/03/2022. R1 was charged for the period of 12/03/2022 – 01/03/2023, totaling $1,059.15 after accounting for the full December 2022 rent of $11,575.00 and $125.00 recurring TIMs fee charged on 12/01/2022. Therefore, the remaining balance of $1,059.15 ($9.93 recurring TIMs fee + $919.66 monthly rent) is for the three (3) additional days in January 2023 counting for thirty (30) days after R1 moving, 12/03/2022. However, R1 moved out within the thirty (30) day notice was that was received by the facility on 11/30/2022. The facility dropped the balance of $1,059.15 on 04/30/2024. The information obtained for this investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation “Facility staff financially abused resident” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

Pg. 2 Unqualified staff are administering medication to residents. On the allegation that staff are administering medications to residents, it is the reporting party’s concern that unqualified staff are conducting blood sugar tests and giving insulin injections to residents. To investigate the allegation, LPA Urena conducted staff and residents’ interviews and reviewed documents pertinent to the allegation. Residents’ interviews revealed that they receive insulin injections from different staff. Three (3) out of five (5) residents were able to provide the names of staff who administer the injections; the names provided names were of staff who are considered skilled professionals. The staff interviewed stated that the Licensed Vocational Nurse (LVN) give the insulin injections to residents who have prescriptions for insulin, and also conduct blood sugar testing. The staff added that they have seven residents with prescriptions for insulin. Six out of seven residents have a device called either Freestyle-Libre or Dexcone attached to their arm; these devices give automatic blood sugar level readings through an application on a reading phone type device. The arm devices are changed every two weeks by the LVNs. One resident is using the Freestyle device and uses the lancet to prick their finger and get a reading through a device used for this type of blood sugar testing. The residents receive the insulin injections once to three times a day, depending on the physicians’ orders. The insulin injections are administered to the residents in the comfort of their rooms. The insulin injections are administered in the residents’ abdomen area. The insulin injections are recorded in the facility’s electronic system ‘Acuflow-Electronic Medication Administration Record(E-MAR) by the staff who administered the injections. The initials of the staff are then recorded in the E-MAR. LPA Urena conducted record review of printouts of the E-MAR and ‘Diabetic Flow Sheet’ (DFS). During the record review, it was observed that the initials of staff 1 (S1) are printed on the DFS for resident 1 (R1) as the staff who administered the insulin injection on 08/12/2023 at 8:00 a.m. Furthermore, LPA Urena observed that the E-MAR printouts for resident 2 (R2) dated for August 2023, have the initials of staff 2 (S2), and the initials are printed on at least seven (7) different dates during the month of August 2023, which shows that S2 administered insulin injections to R2 and conducted blood sugar testing. Additionally, it was observed that the E-MAR records for R3, R4 and R5, indicate that S3 administered insulin injections and conducted blood sugar testing during the month of August 2023. Staff S1, S2, and S3 are not appropriately skilled professionals to administer injections. Continues on Pg. 3 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 Pg. 3 Based on the information obtained through interviews and record review, and although staff and residents’ interviews revealed that skilled professionals had administered the insulin injections to residents; the record review revealed that five (5) out of seven(7) residents had received either an injection or blood sugar testing from staff (S1, S2, and S3) who are not deemed based on regulations, skilled professionals. Therefore, the allegation that ‘Unqualified staff are administering medication to residents’, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Exit interview was conducted. A copy of the report and Appeal Rights were issued. 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 Pg 2. Staff are not keeping accurate resident records. On the allegation that staff are not keeping accurate resident records, it is the reporting party’s concern that medication errors have occurred due to the mishandling of medications. To investigate the allegation, LPA Urena conducted a random medication audit, and interviewed staff. During the medication audit conducted for 10 residents and compared against the Centrally Stored Medication and Destruction Record (LIC622), no errors were found. The medications are generally contained in bubble packets created by the pharmacy filling the prescriptions. The packets are labeled as AM, PM, and Night. Staff interviews revealed that the medication assistance happens at the Wellness Center (WC). Residents are accompanied by their caregivers to the WC. At the WC a med tech or a Licensed Vocational Nurse (LVN) signs in to the system, gathers the resident’s box of medications, opens the Electronic Medication Administration Record(E-MAR) scans the bubble/multi packet barcode; after scanning the barcode, a picture of the pills and the resident's picture appear on the screen and is compared to the resident standing in front of the staff. Furthermore, if a medication has been discontinued by the doctor, a red flash pops up indicating that the medication has been discontinued. The med tech or the LVN then pops the pills from the bubble packet, and hands them to the resident in a cup. Residents receive the medications along with a glass of water and take the medication in front of the staff. Based on the information obtained through record review and staff interviews, it appears that the current facility’s system Acuflow-Electronic Medication Administration Record(E-MAR), ensures that staff keep accurate medication records, assisting with the medication, and ensuring that staff assisting with medications are recorded. Therefore, the allegation of ‘Staff are not keeping accurate resident records’ is deemed Unsubstantiated at this time. Continues on pg 3 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 Pg.3 Staff are not submitting unusual incident reports. On the allegation that staff are not submitting unusual incident reports, it is the reporting party’s concern that facility staff are not reporting incidents and medication’s errors to the Community Care Licensing Department. To investigate the allegation, the LPA conducted record review of incidents reports and interviewed six (6) staff about the steps they follow to report incidents, which staff is responsible for filling out the incident reports (LIC 624) and submitting them to the CCLD. Staff interviews revealed that any medication errors are reported to the Director of Residents Care Services (DRCS). The DRCS submits reports to the Executive Director (ED), and the ED submits reports to CCLD. The protocol is to immediately inform the resident’s responsible party/family, and the physician of the medication error. Residents are under observation and vitals are taken for the next 24 to 48 hours, and the ED conducts an internal investigation. LPA Urena conducted an internal data system review of LICs 624 submitted by the facility to CCLD from 01/01/2023 to 07/01/2024; no LICs 624 related to medication errors were found; however, the LPA found several LICs 624 submitted by the facility to notify the CCLD about incidents that occurred at the facility. Based on the information obtained through interviews and record review, the allegation of staff not submitting unusual incident reports could not be verified. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted. Copy of the report was issued.

Licensing Program Analysts (LPAs) Emily Peraldi and Sandra Urena arrived at the facility unannounced to conduct a required annual visit. At 8:00 a.m., the LPA was greeted by staff and explained the reason for the visit. At 9:35 a.m., the Director of Resident Care Services (DRCS), Courtney Barber arrived at the facility. Files: Between 9:25 a.m. and 11:55 a.m., the LPAs conducted a file review for seven (7) residents and seven (7) staff. Resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order. Starting at 9:35 a.m., LPA Peraldi conducted a review of medication, medication records, policy and procedures with medication technician for ten (10) residents. No errors observed during the medication review. The LPAs obtained a copy of the resident roster, and staff schedule. Due to time constraints, the LPA will return at a later date to complete the annual. Exit interview conducted. A copy of the report was provided.

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a CASE MANAGEMENT Continuation Annual inspection. The LPA met with Executive Director (ED), Abigail Trexler , and explained the reason for the visit. On 06/27/2023, Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA met with Executive Director (ED), Abigail Trexler, and explained the reason for the visit. During today’s inspection the LPA conducted records review at 11:00 a.m. RECORDS: Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:45 p.m.; medications are centrally stored and locked in carts in the Wellness Center located on the second floor and first floor; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL : Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs discussed the new PIN changes regarding infection control. The LPAs obtained the following documents: - LIC500 Personnel Report - LIC9020 Client Roster No deficiencies were cited at this time. Exit interview conducted with facility representative. A copy of the report was issued.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced case management-incident visit. The LPA met with the Executive Director Abigail Traxler, and explained the reason for the visit. The purpose of today’s visit is to follow up on an incident report received by the Community Care Licensing Division (CCLD) office on 06/26/2023, regarding an intruder who gained entry to the facility via the front double doors, and accessed entry to the fourth floor via the elevator. During today’s visit, the LPA interviewed residents, and the ED between 10:25 a.m. and 11:10 a.m. Additional interviews are pending due to staff who observed the incident were not present at the time of the visit. The LPA obtained and reviewed records pertaining to the incident at 12:35 p.m. Further investigation is needed before delivering the findings. Exit interview was conducted with the Executive Director. A copy of the report was issued.