La Posada.

Allegation: Staff prevents residents from using the public restroom by locking the doors. The complaint alleges that in early July 2025 the community/public 1st floor restroom was being locked so that staff had less of restroom assignments because at that time there was only one housekeeper in the building. It is alleged that a resident informed staff that the 1st floor restroom was locked, the resident was told to go upstairs to use the restroom in their room, and the inaccessibility and closure of the 1st floor public restroom caused the resident to have a couple of incontinence accidents on two different occasions. A total of 11 residents were interviewed. Seven (7) out of 11 residents confirmed the allegation. Resident interviews revealed that they were told by staff the 1st floor restroom was locked because residents were falling in the restroom. Residents said that some residents had incontinence accidents because they were not allowed to use the 1st floor restroom. The restroom closure affected residents in care and their visitors. A total of 13 staff were interviewed. Staff acknowledged the 1st floor restroom was locked and inaccessible to residents in order to "prevent injury". Staff interviews revealed that in early July 2025 Executive Director and medication technicians ordered housekeepers to keep the 1st floor restroom locked because a resident fell twice in the 1st floor restroom. Staff said that previous to the restroom closure directive, the restroom was only closed during maintenance or cleaning. It was established that residents who were able to to to the restroom on their own may be given access to the public restroom, and those that required incontinence assistance were to be escorted by staff to their room bathroom. According to interviews, there were several residents that had incontinence accidents because they did not get to their room bathroom in time. Staff interviews revealed that residents and visitors did not have access to the 1st floor public restroom without getting the key from the lobby receptionist. The findings revealed that the day receptionist shift is not 24 hours a day, and once their shift was over, there was no staff at the front to give residents access to the 1st floor public restroom. 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 did not provide residents meal in a timely manner. It is alleged that in July 2025 meals were not being served on time and on July 16, 2025, lunch service was served at 12:38 PM, instead of 12:00 PM, and as a result residents and their families made attempts to reach out to Administration staff about the late meals, but they did not receive a response. A total of thirteen (13) staff were interviewed, of which nine (9) staff acknowledged that meals have been served late due to staff shortages. Staff interviews revealed that there was one occasion in which the lunch meal was served very late, close to 1 hour after the regular lunch time of 12 PM. The Dining Service Director confirmed that in the month of July 2025 meals were not being served on time because they were not familiar with the schedule since they had just began working at the facility on June 26, 2025. All kitchen staff interviewed confirmed the allegation and stated that on days where there are staffing shortages meals may be served late. For instance, during Summer 2025 there were kitchen/dietary aide staff shortages and at times there was only 1 or 2 dietary aides. According to staff, there are supposed to be 2 cooks and four aides per shift. Additionally, a new directive from Administration and Dining Services Director instructed kitchen staff to take meal trays to resident rooms, and previous practice had caregivers take the meal trays to the resident rooms. A total of 11 residents were interviewed, of which 8 confirmed the allegation. They stated that meals were being served late and cold during July 2025 because there was staffing shortages. Residents stated that meal serving times were not being followed because lunch service is supposed to be at 12:00 PM and during several weeks in July 2025 lunch and sometimes dinner meals were served approximately 30 minutes late but staff still wanted residents to be in the dining room by 12 PM and 5 PM despite meal service delays. The findings indicate that in 2025 there were changes to the Dining Services Director position that resulted in meal time and staff shortages. There is sufficient information to support 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 Allegation: Facility does not have a full-time Activity Director. It was reported that the facility did not have a full-time Activity Director for "a long time". In July 2025, the facility Activity Assistant went on leave and as a result there were limited or no resident engagement activities. According to 13 staff interviews, the facility did not have an Activity Director since the end of 2024 through October 2025. A staff member was appointed the Activities Assistant position in 2024, but went on leave in July 2025. As a result, there were no formal resident engagement activities like., exercise classes, bingo, arts and crafts, music programming, tea with friends, and board games. Receptionists were instructed to place coloring pages in the common areas as "independent activities" for residents. Weekend receptionists make popcorn & lemonade. During the initial complaint visit (7/22/25), LPA reviewed the weekly and monthly activities calendar. On 7/22/25, arts and crafts, manicures, bingo, nostalgic movies, ice cream/milk shake, and cocktail music was scheduled, but no activities were observed during the visit. A total of 11 residents were interviewed, of which 8 residents stated that there has not been an Activity Director "in a very long time" and the Activity Assistant was off on leave. Residents said there was no activity calendar posted and LPA confirmed during the visit that there was no activity calendar posted. Therefore, there is sufficient information to support the allegation. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Pursuant to Title 22, California Code of Regulations, a deficiencies are cited. An exit interview conducted, copy of the report and appeal rights was provided to Executive Director Colleen Rozatti.

Licensing Program Analyst (LPA) Galarza conducted a subsequent unannounced Annual Continuation visit to finish reviewing staff and resident records and issue citations observed during yesterday's visit. Interim Executive Director Anahi Reyes assisted with the visit. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. Infection Control: The facility has an Infection Control Plan and ample PPE supplies. Operational Requirements: The facility has a Dementia plan, a fire clearance for 114 non-ambulatory residents age 60 and above, of which 15 residents may be bedridden, and a hospice waiver for 30 residents. Facility does not handle resident money. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 6/2/2026. Physical Plant/Environment Safety: The facility is a three (3) story building consisting of 77 resident rooms. The 1st floor consists of a lobby, dining room with outdoor courtyard, kitchen, medication room, administrative offices, electrical room, public restrooms, laundry room, 21 resident rooms, shaded outdoor courtyard area, and a Memory Care unit with multi-purpose room, and outdoor courtyard. The 2nd floor consists of 28 resident rooms, Bistro area, game room, public restrooms, 2 storage rooms, laundry/housekeeping room, outdoor shaded balcony area, and 2 common areas. The 3rd floor consists of 28 resident rooms, fitness room, theater room, lounge, beauty shop, and outdoor shaded balcony area. Delayed egress is in place in the 1st floor Memory Care unit. 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 continuation - Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Twenty eight (28) resident rooms, common areas, and kitchen were inspected. Resident rooms have required furniture, bedding, linens, and lighting. Exit doors are free of any obstruction. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. There are evacuation chairs on 2nd and 3rd floor stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and fire extinguishers. The last fire inspection was conducted by Code Red Fire Inc. The Memory Care Unit tweezers were found in an unlocked dirty refrigerator freezer in the multi-purpose room, as well as unlocked nail polish & nail polish remover in the arts/crafts cabinet. Room 112's ceiling does not have dry wall, and 204 has a hole above the bathtub ceiling. This issue is currently being investigated in complaint control # 28-AS-20260211084916. Rooms 101, 104, 106, 107,110, 111, 112, 113, 202, 211, 311, 320 beds did not have mattress pads. Staffing: A total of 42 staff members provides care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 2/28/2026. Staff have criminal background clearance and training. Nine (9) staff files were requested. Three (3) files were not provided, including the Executive Director/Administrator's file. Staff (S2, S3 & S5) do not have current 1st Aid/CPR training. Staff (S4 & S6's) files did not have health/TB screenings. Resident Records/Incident Reports: 12 resident files were reviewed. They contained Admission Agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and centrally stored medication records. Five resident files did not have current medical assessments. There were resident files that did not have service plans; however, there is an opened complaint investigation that addresses that issue. RCFE & Ombudsman complaint posters are posted. However, the CCLD RCFE complaint poster posted in the 1st floor hallways does not meet the size 20 x 26 requirement. A technical advisory was 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 Planned Activities: The facility has a posted activity calendar. Sufficient space to accommodate both indoor and outdoor activities was observed in the Memory Care Unit and Assisted Living floors. The facility has a Resident Council. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Dining Services Director has a current Food Handling Certificate. Residents have physician orders for modified diets. A diet list was obtained. However, residents (R4 & R8) require a renal diet and they are not receiving renal diet meals. Per Dining Services Director med-tech/nursing staff have not communicated R4 & R8's renal diet needs to the kitchen staff. Incident Medical and Dental: Centrally stored resident medications were reviewed. Missing medications were observed during yesterday's visit. Citation was issued. Medical and dental transportation is provided by family or 3rd party transportation companies. The facility has a non-operable van and no staff driver. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. Proof of last emergency disaster drill was not provided. Residents with Special Health Needs: There are currently 14 residents receiving hospice services and 15 residents receive home health services, and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and postural support physician orders are on file. Pursuant to Title 22, deficiencies were observed and are cited. Exit interview was conducted with Interim Executive Director Anahi Reyes. A copy of report and appeal rights was issued.

Licensing Program Analysts (LPAs) Galarza and Jewel Baptiste conducted an unannounced Required- 1 year. The purpose of the visit was explained to Business Office Manager Michelle Armendariz. Interim Executive Director Anahi Reyes arrived later. During today's visit the following was completed: A physical plant tour of the entire facility was conducted. Staff files were reviewed. There were three missing files. Some staff files were missing 1st Aid/CPR and health screening/TB tests. Resident files were reviewed. Need and Services plans were missing. Centrally stored medications were reviewed. Four residents were missing physician ordered medications. *Type A citation was issued today. Fire Inspection report was not provided and is pending. Deficiencies were observed and will be cited during the Annual Continuation visit. Exit interview was conducted with Anahi Reyes. A copy of the report and appeal rights was provided.

Allegation: Staff are not providing adequate food service for resident. The complaint alleges residents in the memory care unit are not provided adequate snacks because staff are not always providing snacks to residents, and resident (R1's) authorized representative was asked to buy snacks for the resident. Resident interviews revealed that in January 2025- February 2025 drinks were available in the 1st floor lobby area and/or kitchen. On 2/6/2025, during the physical plant inspection after lunch meal the kitchen, common areas, and Memory Care Unit cabinets and refrigerator, it was observed that the 1st floor lobby area only offered drinks to residents, and the Memory Care Unit refrigerator did not have an adequate supply of snacks in the refrigerator. Staff stated they have never asked R1's authorized representative to pay for snacks. However, staff interviews revealed that the memory care unit did not at that time have on hand snacks for residents every day, and only some staff took initiative to request snacks from kitchen staff if needed. Staff stated that when family request specific snacks that are not typically provided by the facility they are encouraged to bring those snacks to the facility. Staff also stated that snacks should be provided in between regular meal times. Per Admission Agreement, the facility "will serve three (3) nutritionally balanced meals and snacks daily to residents at La Posada." Based on observations and picture evidence, there is sufficient evidence to support the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Beatriz Rome Lui. A copy of the report and appeal rights were provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff are retaliating against resident's authorized representative. The complaint alleges that staff told resident (R1's) authorized representative that transfer/move in arrangements and belongings pick-up from another RCFE would be taken care of by the facility. According to information obtained, Administrator was unprofessional and argued with authorized representative about move-in transfer issues, instructions on hospital bed pick-up and hospice enrollment. It is alleged that Administration staff are retaliating by ending hospice services for R1. A total of nine (9) staff were interviewed. Based on interviews conducted the findings indicate that resident (R1) moved in on December 20, 2024 with active hospice enrollment, but on February 5, 2025 hospice agency terminated services due to "family no longer wishes to receive hospice services." On 2/5/2025, Administration staff notified authorized representative of change. Per record review, the findings indicate that the facility made numerous telephonic and email attempts to speak to R1's authorized representative about care plan, hospice enrollment, and admission agreement, but did not receive a response to meeting requests. Resident (R1's) file was reviewed, it revealed the facility made multiple attempts via telephone calls, texts, emails, and scheduled meetings to communicate with authorized representative regarding representative concerns. However, R1's authorized representative cancelled meetings and/or did not reply to emails and telephone calls. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not have resident or authorized representative sign an admissions agreement upon admission. It is alleged that resident (R1's) authorized representative did not sign an admission agreement when the resident moved in and was emailed an admissions agreement until January 30, 2025. Staff interviews revealed that resident (R1's) authorized representative electronically signed the admission agreement on December 15, 2024, with the exception of page 18. According to interviews and file review, there were multiple attempts made by former Administrator and administration staff to address the missing admission agreement signature. Staff interviews revealed there were multiple meetings scheduled with R1's authorized representative to obtain the missing signature, but the authorized representative denied signing the admission agreement electronically, and accused staff of forging their signature. Executive Director stated the resident moved out on June 4, 2025, and the authorized representative never signed the missing signature on page 18 of the admission agreement. Based on file review conducted today, Dropbox Sign records indicate that the admission agreement was sent electronically to R1's authorized representative on 12/13/2024, and the admission agreement was signed and completed on 12/15/2024. None of the residents interviews supported the allegation. Therefore, there is insufficient evidence to corroborate 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 Allegation: Staff are not treating resident equally. The complaint alleges that memory care resident (R1) is not being treated equally during snack time because if the resident is in their room staff do not give the resident a snack, since residents have to be in the common activity room to receive a snack. Staff interviews revealed that residents in the Memory Care Unit and Assisted Living floors are provided snacks every day. For instance, in the memory care unit staff pass out snacks in the common area room, and if a resident is in their room they are offered snacks or encouraged to pick them up in the common area activity room. Staff stated residents are provided bananas, juice, water, and coffee. According to staff, R1 constantly repeated to staff that they were hungry even after they finished eating their regular meal. Resident (R1) did not require a special diet. When resident (R1) was interviewed they stated staff did not give them snacks, but the resident was not oriented to time or place. Resident interviews revealed all residents are offered snacks in between meals. None of the residents stated they are not treated equally. There is insufficient evidence to support the allegation. Allegation: Staff are not following resident's authorized representative's directives about visitors. It is alleged the facility keeps allowing resident (R1's) other family member to visit the resident despite the authorized representative's directive to restrict the family member from visiting the resident. Staff interviews revealed residents are asked by staff if they would like to see a visitor that arrives at the facility. Resident (R1) resides in the memory care unit and the resident agreed to the family member's visits. Additionally, Administration staff stated the authorized representative did not present a restraining order against the family member they wanted restricted. Based on file review, LPA confirmed there is no restraining order in place. Therefore, staff did not prohibit any family and/or visitors from seeing resident (R1). None of the residents interviewed supported the allegation. There is insufficient evidence to corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to facility Executive Director Beatriz Romeo Lui.

Allegation: Staff did not notify authorized representative of incident. It is alleged that on January 20, 2025, resident (R1's) authorized representative observed a bruise under the resident's right eye and questioned staff about the incident. A total of seven staff were interviewed. Based on interviews conducted, the findings indicate that on January 17, 2025 at approximately 7:30 AM, morning shift caregiver staff (S3) observed the bruise. Caregiver immediately reported the observation to AM shift med-techs, whom typically contact the resident's physician, hospice, and responsible party. However, in this case the two (2) AM med-techs on duty on January 17, 2025 failed to report the incident to family and forgot to communicate the incident with the next shift med-tech. Additionally, the bruise incident was not documented on the facility electronic software system or charting notes. Per Charting Notes records, staff did not document the bruise that was observed on January 17, 2025, but a Skin Integrity Monitoring Form was completed. Staff acknowledged the incident was not reported to R1's responsible party and documentation/communication protocols were not followed. Therefore, there is sufficient evidence to corroborate the allegation. Allegation: Staff are not repositioning resident every 2 hours. It was reported that hospice resident (R1) required repositioning every 2 hours due to a sacral pressure injury, but despite regular hospice wound care the pressure injury was getting worse. Seven (7) staff were interviewed. Caregiver staff stated they checked on the resident every 2 hours, and as the resident's health declined staff were checking on the resident at least every hour. Staff stated sometimes R1 refused to be repositioned every 2 hours because the resident preferred to lay in bed in a flat position due to pain when rotated to the side. Staff acknowledged that sometimes the NOC shift caregiver staff did not log in routine checks. It is unknown if they performed rotations on the resident. One of the NOC shift staff (S8) in question was terminated on January 24, 2025 for misconduct and suspicions of improper handling of cognitively impaired residents during incontinence changes. Bedridden residents were interviewed. One (1) resident stated staff are not repositioning every 2 hours, especially during night time. Charting notes [1/1/25 - 1/29/25], records indicate that the majority of the time R1 was routinely being checked every 2 hours. However, on several dates staff checked the resident past the required repositioning time. In addition, many of the documented checks did not specify whether the resident was repositioned every 2 hours. There is sufficient evidence to corroborate 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 Allegation: Resident received an unexplained injury. On January 17, 2025, AM shift caregiver staff observed a bruise under resident (R1's) right eye. The injury was documented on a Skin Integrity Monitoring Form and med-tech staff were notified. None of the residents interviewed reported staff rough handling incidents that have caused bruising. All seven (7) staff interviewed confirmed that resident (R1) had a bruise under the right eye. Staff interviews revealed that former NOC shift staff (S8) stated that when the resident was being turned the resident's hand hit their own face. Staff stated that R1 was experiencing agitation behaviors during repositioning assistance, and may have unintentionally hit themselves. The majority of staff interviewed do not believe the bruise was intentionally caused by malicious intent, but confirmed the resident sustained an unexplained bruise. Picture evidence was obtained. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Business Office Manager Andrea Lopez. A copy of the report and appeal rights were provided.

Allegation: Staff are prohibiting resident from having visitors. It is alleged that on April 3, 2025 facility staff did not allow a former staff (S5) to visit resident (R1). According to information obtained, the resident's family notified the former staff that resident was "transitioning" i.e., nearing the end of their life and invited the former staff to visit R1. The complaint alleges Executive Director and Administration staff prohibited former staff (S5) from visiting R1 by stating that per Admission Agreement and Human Resource policy no former staff are allowed to visit residents because it is a conflict of interest. Resident (R1) passed away on April 6, 2025; therefore was not interviewed. A total of seven (7) residents were interviewed, of which two (2) stated that former staff were previously allowed to visit residents, but are no longer being allowed. One resident (1) stated they now have to go outside the facility to talk to former staff. Another resident stated that a former staff came to visit the resident, but was not allowed. Four (4) out of seven (7) staff stated they believe former staff should be allowed to visit them. Employee Handbook [April 18, 2023] page 40, "Visitors in the Workplace" states 'To provide for the safety and security of our residents, employees, and the general facility, only authorized visitors are allowed in the workplace. The Residence and Care Agreement, page 14, states "All visitors must register at the front desk when entering La Posada. We reserve the right to remove or deny entry to La Posada to any visitor whom we determine is disruptive or dangerous." Based on record review, the Plan of Operation, Employee Handbook, Residence Care Agreement do not explicitly state that a former employee is not allowed to visit. Therefore, there is evidence to corroborate the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Beatriz Lui. A copy of the report and appeal rights were provided.

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Deficiencies visit due to record review findings while investigating complaint control #: 28-AS-20240805162120. The purpose of the visit was explained to Administrative Assistant Katie Manriquez. On 7/31/2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. An incident report was not submitted to Community Care Licensing within 7 days of the occurrence. Per 87211(a)(B) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. Pursuant to Title 22 California Code of Regulations, a deficiency was cited (refer to LIC 9099D). Exit interview held with Katie Manriquez. A copy of the report and appeal rights were provided.

Staff did not properly transfer a resident resulting in an injury. It is alleged that on July 31, 2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. According to information obtained, when the wet resident was being transferred out of the bath chair to the toilet, the resident was only assisted by one (1) staff (S1) instead of two staff, and staff (S1) gripped R1's hand in order to prevent the resident from falling. According to information obtained, R1 was assessed as a 2-person assist after a previous incident in March 2024 determined the resident was in need of two staff assistance during bathing and transfers. A total of seven (7) staff were interviewed. Staff (S1) stated that on 7/31/24 at approximately 7 AM, R1 was assisted into the bath by two staff, S1 & S2, but left the room to check on the resident next door, and was not present for assistance out of the bath chair. Staff (S2) stated that S1 screamed for S2's help. R1 had a hand a long and thin skin tear on the right hand. Staff (S1) said that R1's son had instructed staff to transfer the resident out of the bath by holding their hands. Both staff stated they immediately notified former med-tech staff (S8) of the incident and 1st Aid care was provided to the resident. Staff (S1) stated a skin integrity assessment form was completed, it was documented on the end of shift book and shower chart located in R1's room. Wellness Director and Administrator confirmed that former med-tech (S8) did not notify Administrator or Wellness Director, write any chart notes, notify R1's Physician or family, nor mentioned the injury at change of shift. Administrator stated that S8 communicated with PM med-tech former staff (S9) to monitor and change the bandage, but said the tear was minor and 1 cm in length. Staff (S)9 did not check the wound until late at night and discovered the wound needed medical attention. At approximately 10:30 PM, R1 was sent out to the hospital as non-emergency. Based on the picture of the injury, staff agreed the hand injury required a medical assessment by a physician after AM med-tech (S8) assessed the hand injury during the 1st Aid assessment. Therefore, there is sufficient evidence to corroborate the allegation. (2 of 7) 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 did not seek timely medical attention for a resident. It is alleged that on 7/31/2024, resident (R1) sustained a hand injury at approximately 7 AM that required medical attention because the skin tear was approximately four inches with exposed flesh. According to information obtained, PM caregiver staff (S9) called Kaiser Permanente Hospital for an ambulance until approximately 10 PM. The hospital doctor applied glue and wrapped the wound with gauze. The resident returned to the facility at approximately 4 AM. Based on seven (7) staff interviews the findings revealed that former AM med-tech staff (S8) failed to call R1's physician for directions regarding the skin tear, and did not seek timely medical attention for the hand wound tear that required medical attention. Caregiver staff interviewed stated they followed protocol by immediately reporting the incident to the AM med-tech staff, whom after the initial injury assessment should have seek out medical advice and/or medical attention. All staff acknowledged R1's physician should have been contacted immediately after the injury. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not ensure that resident's toileting needs were met. The complaint alleges that resident (R1) requires full assistance with incontinence care and is supposed to be changed at least every 2 hours. It was reported that the incontinence logs in the resident’s room had 6-hour gaps of missing staff documentation indicating incontinence care was performed. The resident’s responsible party and/or other family members arrive at the facility daily at 9 AM and stay until approximately 9:30 PM. According to the report, family have observed the resident soiled primarily during early morning hours. On Saturday August 10, 2024, the responsible party arrived at approximately 9 AM, it was observed that the bed sheets were soiled with urine. Six (6) out of 7 staff denied the allegation and stated resident (R1) is being checked every 2 hours and changed, but that sometimes staff forget to document the completed task. Two (2) staff stated that during Summer 2024 there were reports that night shift caregivers were not completing incontinence care as required. LPA reviewed and gathered pertinent documentation that revealed that facility caregivers did not perform 2 hour checks on the resident on numerous occasions in the month of July 2024.Therefore, the allegation is deemed substantiated. (3 of 7) 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 mismanaged resident's medication . It was reported that on July 6, 2024, AM med-tech staff left R1’s responsible party a note asking them to contact Kaiser requesting a refill for eye drop medication “Latanoprost 0.005 %” because the medication ran out. The medication was picked up by family until July 9, 2024, because staff informed family staff were not able to pick up the medication. According to the report, the facility has authorization to request refills from Kaiser and Yorba Linda pharmacy. Moreover, it is also alleged that on August 8, 2024, at 6 PM, R1 was administered bedtime medication Donepezil HCL 5mg, which is supposed to be administered between 8 PM – 9PM. Family was in the room when Wellness Director went into R1’s room at 9 PM to administer the bedtime medication that had already been administered by the med-tech at 6 PM. A total of seven (7) staff were interviewed . It was acknowledged that some of R1’s medications were not administered on August 8, 2024, and that med-tech administered a bedtime medication at 6PM but failed to document on the Medication Administration Report (MAR). Wellness Director confirmed that on August 8, 2024, R1’s family stated the medication had already been administered at 6 PM. Therefore, Donepezil was not administered. According to staff interviews, bedtime medications are typically dispensed at 7:30 PM. MAR records indicate eye drops Latanoprost 0.005% appear to have not been given consistently. Staff acknowledged that med-techs should have requested the eye drop refill in a timely manner. Records indicate there is sufficient evidence to corroborate the allegation. Allegation: Staff do not ensure a safe environment is provided for residents. It is alleged that In July 2024 the front doors of the facility were being left unlocked 24 hours a day even though the front door entrance is supposed to be locked at 7 PM, and young male (18-22) outsiders have been observed entering the facility after 8PM to use the 1 st floor public restroom. On August 1, 2024, resident (R1’s) responsible party emailed Administrator notifying her of the safety concerns regarding the unlocked doors, and she immediately addressed the issue with PM staff. However, on August 3, 2024, R1’s responsible party went to the facility at midnight to check if the front door was locked. It was found to be unlocked and accessible to outsiders. All seven (7) staff confirmed that the front doors were being left unlocked by PM staff. According to staff interviews, PM med-techs are responsible for locking the doors at 7PM but have been known to leave the doors unlocked when they exit the facility for breaks. Staff reported that on several occasions homeless in the area have tried entering the building, and after 6 PM there is no receptionist on duty. Therefore, the allegation is substantiated. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Pursuant to Title 22 California Code of Regulations, the following deficiencies were cited (refer to LIC 9099D). Exit Interview was conducted, citations issued, appeal rights discussed, and a copy of the report was issued to Administrative Assistant Katie Manriquez. 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 did not report incident involving resident as required. It was reported that resident (R1’s) responsible parties were not immediately notified of the hand tear injury sustained at approximately 7 AM on July 31, 2024. The complaint alleges that R1’s son/responsible party arrived at the facility at approximately 9 AM and that is when staff informed the responsible party of the injury. A total of seven (7) staff interviews were conducted. The findings reveal that when a resident sustains a serious injury the residents’ responsible party is immediately notified if the resident is being transported by emergency services. However, if the resident’s injury is not deemed serious then, then med-techs may notify the responsible party a little later. In this case, former med-tech (S8) did not categorize the injury as serious, and since R1’s family members and responsible party visited the resident at approximately 9 AM daily, staff waited to communicate to the responsible party upon arrival to the facility. Based on information gathered there is insufficient evidence to prove the allegation, because the resident’s responsible party was notified within a reasonable time according to records reviewed. Allegation: Staff failed to provide adequate food service. It is alleged that on Saturday, August 10, 2024, resident (R1) informed their responsible party that they had not eaten breakfast because staff dropped the cereal on the floor, picked it up, and atte

Licensing Program Analyst (LPA) Galarza conducted an unannounced Annual Continuation visit. The purpose of the visit was explained to Administrator Diana Bautista. There facility serves residents 60 years and older. The following 12 (CARE) tool domains were utilized during the inspection. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs). Operational Requirements: The facility has a Dementia plan, a fire clearance for 114 non-ambulatory residents age 60 and above, of which 15 residents may be bedridden, and a hospice waiver for 30 residents. Facility does not handle resident money. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 5/20/2025. Physical Plant/Environment Safety: The facility is a three (3) story building consisting of 77 resident rooms. The 1st floor consists of a lobby, dining room with outdoor courtyard, kitchen, medication room, administrative offices, electrical room, public restrooms, laundry room, 21 resident rooms, shaded outdoor courtyard area, and a Memory Care unit with multi-purpose room, and outdoor courtyard. The 2nd floor consists of 28 resident rooms, Bistro area, game room, public restrooms, 2 storage rooms, laundry/housekeeping room, outdoor shaded balcony area, and 2 common areas. The 3rd floor consists of 28 resident rooms, fitness room, theater room, lounge, beauty shop, and outdoor shaded balcony area. Delayed egress is in place in the 1st floor Memory Care unit. There are evacuation chairs on 2nd and 3rd floor stairwells to be used during an emergency as a path of egress from the facility to safety. *See 809C pages. 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 continuation - Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has fully charged fire extinguishers. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. 12 out 22 resident rooms and a kitchen sink hot water readings measured between 120 DF 124.2 DF. On 6/28/2024, County of LA Fire Department conducted an annual inspection.The sprinkler system, alarms, fire connections, kitchen hood, and water flow alarms were inspected. Violations were found. All maintenance records shall be kept in the facility. Re-inspection will be conducted on 11/20/2024. Staffing: A total of 63 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expired 8/15/2024 and is pending approval from CCL Recertification Unit. Staff have criminal background clearance. Eleven (11) staff files were reviewed. 9 out 11 staff files had expired 1st Aid/CPR training or no proof of training. 6 out 11 staff files do not have required annual training hours. 2 out 11 staff files do not have health and TB clearance. Resident Records/Incident Reports: Ten (10) resident files were reviewed. They contained admission agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records are in place. RCFE & Ombudsman complaint poster were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the entrance area. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Twenty six (26) residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Dining Services Director's Food Handling Certificate expires 11/16/2025. 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 Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or 3rd party transportation companies. The facility has a non-operable van and no staff driver. An medication error was observed during medication review. Two (2) of Resident (R1's) medications listed on the Medication Administration Record were not filled. Acetaminophen 325 mg, 2 tabs every 4 hours PRN for fever over 100DF & Acetaminophen 325 mg 2 tabs every 6 hrs PRN for mild pain. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 9/23/2024.. Residents with Special Health Needs: There are currently 19 residents are receiving hospice services, 6 receive home health services, and no residents have prohibited health conditions. Individual Service Plans and Appraisals are on file. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in some resident rooms, as well as full rails were observed in hospice residents. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights was issued.

Allegation: Staff did not provide resident’s authorized representative a copy of the admission agreement in a timely manner. The complaint alleges that resident (R1's) responsible party never received a copy of the signed Admission Agreement after multiple requests addressed to Administration staff. Based on record review, the findings indicate that resident (R1) moved in to the facility on November 17, 2023. The Admission Agreement was provided until August 5, 2024. LPA obtained a copy of the Admission Agreement, and it was determined the Admission Agreement signed and provided to R1's responsible party is the former licensee's Admission Agreement. On 12/7/2023, the facility was issued a citation for issuing Admission Agreements that were in place when the facility was owned by a previous licensee. Administrator acknowledged they did not provide a copy, and the copy provided is not the correct form. Therefore, there is sufficient evidence to corroborate the allegation. A civil penalty is being assessed. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.

Allegation: Facility staff are not making arrangements to meet residents' health needs. It was reported that resident (R1's) primary care physician informed staff that the resident's healthcare plan was contacted requesting a Cardiologist and Pulmonologist consult, but the facility did not follow through because staff stated that they do not provide transportation to medical appointments. Based on record review, resident (R1) has had a decline in health during the past year, and was hospitalized from June 21, 2024 - June 24, 2024 and placed on home health upon return to the facility. The resident had been enrolled in home health services earlier in the year. Per record review, on July 9, 2024, there was communication between Wellness Director and R1's Medical Doctor, in which MD informed staff that a Cardiologist and Pulmonologist consult referral was sent to R1's insurance provider, as well as a transportation referral. Three staff were interviewed, they confirmed the facility got verbal notification from Medical Doctor that R1 required a Cardiologist and Pulmonologist consult, but stated that they did not receive written referral information for the specialists. Facility charting notes confirm that R1's Doctor informed staff. Resident (R1's) family member was interviewed. They confirmed R1 has not been seen by specialist doctors and was not notified by facility staff that the primary care physician made the facility aware of the referrals on July 9, 2024. Therefore, the residents health needs are not being met. Allegation: Facility staff are not ensuring that residents are receiving an annual medical assessment as required. According to information obtained on June 13, 2024, facility med-tech staff contacted resident (R1's) primary care physician requesting medication refills for 4 medications. However, R1's physician informed staff that the resident has not been seen at the doctor's office in over 2 years. Therefore, the medications would not be refilled. Records indicate the resident moved in 12/12/2022, and upon move-in a Physician's Report dated 12/6/2022 was obtained. A total of 7 residents were interviewed, none reported issues pertaining to the allegation. Based on record review, resident (R1) has mild cognitive impairment and no Dementia. However, record review and staff interviews revealed that resident (R1) was sent out to urgent care in December 2023. A change in condition was noted. On 2/21/2024, the resident was enrolled in home health services, and was sent out to the hospital in early March 2024. In May 2024, staff observed physical changes in need of medical attention. On June 21, 2024, R1 was sent out to the hospital and returned on June 24, 2024, with physical therapy physician order. On July 22, 2024, R1 was enrolled in hospice care. Staff acknowledged R1 had changes in condition since early January 2024, but did not the contact the resident's primary care physician to schedule an annual medical exam. LPA conducted a visit on 7/25/2024 and collected R1's Physician's Report dated 12/6/2022. After that visit, staff obtained an updated Physician's Report dated (7/29/2024) from hospice MD, which indicates the resident has heart failure and requires total care. Staff observed deterioration of physical health condition for months but did not bring to the attention of R1's physician. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED . Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.

Allegation: Staff are not administering medications as prescribed. It is alleged that medication technicians were not refilling medications in a timely manner, pills were being popped but not given to residents, or the pills were not popped at all during the months of May 2024- June 2024. Information obtained alleges that there were at least 10 residents that were not receiving medications as directed by their physicians. Staff interviews revealed that the facility has been experiencing issues with medication technicians during the last 4- 6 months, because med-tech's were not fulfilling their job responsibilities i.e., documenting on the electronic Medication Administration Record (MAR) that the medications were dispensed, or calling for refills with advance notice. Staff stated medications were being administered but there were MAR errors, and lack of documentation on the MAR to prove staff dispensed the medications. A total of 8 residents were interviewed, none reported knowledge of inappropriate dispensing of medications. However, per record review of Medication Administration Records (MAR) of 10 residents, the findings indicate that multiple residents went days without medication administration by med-tech staff. The lack of documentation was observed in all shifts. There is sufficient evidence to corroborate the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Lack of supervision resulted in residents assaulting other residents in care . It is alleged that the facility is failing to ensure the health and safety of residents because residents have been sexually assaulted by resident(s). According to information obtained, management staff have knowledge that there is a known registered sexual offender residing at the facility and were made aware of incidents of sexual inappropriateness by resident (R1) towards resident (R2), and possibly towards resident (R3). Additionally, another resident (R4) allegedly verbally assaults residents with sexual comments and conducts themselves in an inappropriate manner towards staff. It was reported that R1 was observed entering the room of a cognitively impaired, non-ambulatory resident. A total of seven (7) staff were interviewed, of which none reported knowledge of suspected sexual assaults towards residents by R1 or R4. Staff stated they have not observed R1 & R4 act inappropriately with other residents. However, all staff stated that R4, has cognitive impairment and frequently says sexual comments to female staff, but stated none of the residents have reported sexual inappropriateness or assault. A total of 8 residents were interviewed, of which all denied the allegation. Residents (R1 & R2) denied the allegation. There is 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 did or did not occur, therefore the allegation is Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to facility Administrator Diana Bautista.

Licensing Program Analyst (LPA) Galarza & Mayra Cota initiated a case management visit due to observations during complaint investigation control #: 28-AS-20240829114254. The purpose of the visit was explained to Administrator Diana Bautista. Rooms 301, 314 & 326 have oxygen tanks in their rooms, and a "No Smoking-Oxygen in Use" sign was not posted outside resident room doors, which poses/posed a potential health, safety or personal rights risk to persons in care. Per Title 22, a deficiency was cited. Exit interview conducted with Diana Bautista. A copy of the report and appeal rights were issued.

Allegation: Staff does not ensure care needs of resident are being met. It is alleged that resident (R1) has missed multiple dialysis clinic appointments as a result of transportation issues. According to information obtained, on dates June 6, 2024, June 18, 2024, June 20, 2024, June 22, 2024, and July 4, 2024 the resident was not dialyzed at Davita Dialysis clinic. Resident (R1) was interviewed and they stated that they require dialysis treatment three times a week, and is transported to the appointments via Access transportation services. The resident stated that in the recent month three (3) appointments have been missed. A total of five (5) staff were interviewed, of which all confirmed the resident has missed several dialysis appointments due to transportation issues with Access transport services. On Thursday, June 6, 2024, the resident was waiting outside in the patio area for Access van, and the van drove off without picking up the resident. Staff noticed the resident had not been picked up. Staff (S3) notified Access transportation and R1's family. Staff were on hold for 1 hour with Access, and they were told that pick-up appointments require 24 hour advance scheduling. Therefore, would not be able to transport the resident that day. Family was not able to make alternate arrangements for transport. Medical providers were interviewed, it was confirmed that resident (R1) missed dialysis appointments on June 6, 2024 and July 4, 2024. The facility has a transportation van parked in the parking lot, but does not provide transportation services to residents because they do not have an assigned driver. Per admission agreement, the facility is to "make available to residents, or otherwise assure the provision of, scheduled transportation to the nearest facilities for medical and dental appointments...." Therefore, there is sufficient evidence to corroborate the allegation. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiency visit in conjunction with a complaint visit, 28-AS-20230131141908. This report is being generated to address the deficiency observed. During the course of the complaint investigation, Investigative branch and CCL found out that the facility failed to meet the reporting requirements in which facility did not submit an Unusual Incident/Injury Report concerning R1' fall on 10/14/2022. Deficiency is cited on LIC 809D. An exit interview was conducted, and a copy of this report was provided to Diana Bautista-Martinez, Executive Director along with the Appeals Rights.

When an overnight shift caregiver last checked on R1 at 0530 hours on 10/14/2022, she noted R1 was fine. A staff entered R1’s bedroom at 0600 hours to give her Ativan as a matter of course, not because of documented agitation, and it appears R1 was left in bed after the interaction. The majority of staff interviews conducted revealed that R1 was always checked first at the beginning of the morning shift (0600 hours) precisely because of being a fall risk. It is unclear why R1 would be left unattended in her bedroom after she was known to be awake. A morning shift staff documented that her first check was at 0630 hours, but based on an Internal Incident Report, this staff checked on R1 at 0700 hours, which is more consistent with her past checks but still within the facility’s safety check window of every two hours. Though R1 appears to have fallen in between staff rounds, sometime between 0600 and 0700 hours, her wandering behavior and attempts to get out of bed without assistance should have warranted attention. R1 was transported to the hospital and was diagnosed with a left hip fracture for which she underwent a left hemiarthroplasty. The allegation facility Neglect/Lack of Supervision resulted in R1’s fall is therefore Substantiated. In regards to the allegation: “Staff did not seek medical attention for resident in a timely manner.” It is alleged that R1 did not receive timely medical attention after suffering a fall and being in pain for several days. This allegation was investigated and completed by Investigator Santana with the Investigations Branch. Interviews conducted revealed that after R1 was found on her bedroom floor sometime between 0600-0700 hours on 10/14/2022, S3 assessed R1 and concluded she had not sustained injury, since there was no visible injury and R1 was able to take a few steps with her walker without complaining of any pain. S3 did not call 911 despite the fall having been unwitnessed because there was no apparent injury and R1 was on hospice, but S1-S2 conceded that the S3 should have called 911 even though R1 was on hospice because of uncertainty about whether R1 hit her head. S3 instead notified VITAS Hospice, likely at 0805 hours that same day, but a VITAS nurse did not arrive to assess R1 until 10/17/2022. Interviews, facility phone records, and VITAS records suggest the facility did not inform VITAS about R1’s change of condition despite calls from VITAS nurse on 10/15/2022 and 10/16/2022 to ask about R1. R1’s change of condition was evident based on facility staff member interviews and documentation, noting that after the fall, R1 was no longer attempting to get up from her wheelchair to bang on windows, which she had done as recently as the day prior. Additionally, R1 was noted as being sleepy and as sleeping the majority of the day on the three days following the fall. While the facility suggested this lethargy could have been attributed to Ativan, R1 had been taking the same amount of Ativan since 10/10/2022, when R1 was still agitated. A VITAS nurse assessed R1 on 10/17/2022 but did not get R1 out of bed. When a staff attempted to get R1 out of bed, at family member’s request, on the afternoon of 10/17/2022, R1 screamed out “in excruciating pain,” saying her back hurt. R1 was transported to the hospital on 10/17/2022 for congestion and left lower abdominal pain and was found to have a fractured left hip that was within two weeks old. R1 ultimately underwent a hip replacement. Had the facility called 911 on 10/14/2022, it is likely R1 could have been treated sooner. The allegation that facility Neglect/Lack of Supervision contributed to a delay in obtaining medical attention for R1 is therefore Substantiated. ***An immediate civil penalty will be issued today, in the amount of $500 due to neglect/lack of supervision which contributed to a delay in obtaining medical attention in which resident sustained a hip fracture. *** At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date. An exit interview was conducted, and a copy of this report was provided to the Administrator along with the Appeals Rights.

Allegation: Staff did not refill residents medication timely. It is alleged that on October 5, 2023 at approximately 9:30 PM, resident (R1's) blood sugar level was 534 because facility staff failed to reorder insulin medication. According to information obtained PM shift facility staff did not dispense the insulin medication before the resident's dinner meal, which resulted in a dangerous blood sugar level. A total of seven (7) staff were interviewed, which included the staff (S1) that was on shift on 10/5/23. Staff (S1) stated that R1's blood sugar was checked in the early afternoon hours and "it was high". Staff (S1) stated they went to the medication room and there was no insulin left, and the insulin order indicated "zero refills". Therefore, S1 called the pharmacy and they were not able to refill the medication without a current physician order. According to S1, they faxed R1's MD, but did not receive a response. Staff (S1) stated that they spoke to R1 and informed the resident that they could wait for the emergency insulin delivery and/or offered to transport the resident to the hospital. Staff acknowledged they waited "4 hours" to notify the Wellness Nurse and family because they were the only med-tech on duty in the PM shift. All staff interviewed acknowledged that the med-tech staff failed to order insulin medication when it was observed the resident was running low. According to facility protocol, med-techs are supposed to contact the doctor when medication refills are needed. Wellness Director acknowledged that med-tech staff knew the day before R1 ran out of insulin that a new order would be needed. It was stated that the AM med-tech staff should have ordered the insulin, but none of the staff documented the medications needed to be ordered. Family was contacted and they transported R1 to the hospital in order for the resident to be evaluated and so they could receive insulin medication. Facility staff did not call 911 emergency. The findings indicate med-tech staff failed to order R1's insulin medication after observing the insulin supply was running low. There is sufficient evidence to corroborate the allegation. Allegation: Staff gave resident another residents medication. It is alleged that on Sunday, October 29, 2023, med-tech staff (S2) dispensed four (4) wrong medications to resident (R1). According to information obtained, R1 was dispensed their evening medications, and also dispensed another resident's medications. Staff interviews revealed that staff (S1) left another resident's medications in R1's room, and asked other caregivers to check in on R1 and to get the other resident's medications that were left in the room. When staff (S2) went to the room, the other resident's medications were there, and staff assumed they belonged to R1. Therefore, S2 asked the resident to take their medications. According to interviews, staff (S2) misunderstood the instructions given by S1. Per file review, R1 has a diagnosis of early on-set Dementia. All staff interviewed acknowledged the medication error. Per facility protocol, staff cannot leave medications unlocked. Family was notified of medication error and transported the resident to the local hospital. Staff did not call 911 emergency. Therefore, staff negligence is corroborated. 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 falsified documents. It is alleged that the incident report furnished upon request of R1's authorized representative pertaining to the October 5, 2023, in which med-tech staff failed to order and obtain insulin medication for R1 omitted the fact that insulin medication was not dispensed because the facility failed to refill and obtain a new physician order for the medication. LPA obtained a copy of the 2 incident reports provided to R1's authorized representative and compared it to what was submitted by staff to the Department of Social Services Community Care Licensing Division (CCLD) Regional Office. CCLD received a handwritten incident report completed by staff (S1), that stated that R1 wanted to be sent out to the hospital due to high blood sugar level readings, is waiting for insulin refill medication, and that paramedics were called and resident was transported to PIH Whittier Hospital. Staff (S1) stated that they called the paramedics for another resident and mistakenly mixed up the incidents. Med-techs, caregivers, and Wellness Director are in charge of filling out incident reports, which are then submitted to CCLD. In this case, the Wellness Director faxed the handwritten incident report that had incorrect information. A 2nd incident report was created and typed, and then provided to R1's authorized representative after family brought the false statements noted on the incident report to facility staff. However, the 2nd incident report was never faxed to CCLD. Therefore, there is sufficient evidence to corroborate that staff (S1) falsified documents. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.

Allegation: Staff are not following resident's care plan appropriately. It is alleged that the facility has been understaffed for several months and staff are falling behind on their work responsibilities i.e., shower assistance, distribution of medications in a timely manner, and checks on hospice and home health residents. Seven (7) residents were interviewed, of which four (4) stated that they are not being bathe as indicated in their care plans and admission agreements. Two (2) residents stated that they they had not been bathe in over 1 week, and they never know when they are going to be bathe because staff are not following their regular shower schedule. A total of seven (7) staff were interviewed. Four (4) out of seven staff confirmed that resident's care plans are not being followed as a result of staffing shortages. Staff reported that due to the staffing shortages staff are working 6 days a week, and they are still not meeting their needs. For example, a resident's wound was only being cleaned during day shift hours because there was insufficient staffing in the NOC shift, and other residents were not being provided incontinence care as required because when staff started their shift they were observing that the residents on the rotation log were not being changed because their clothes were soiled and wet. Staff stated that weekends and evenings are very challenging for staff because of staff shortages. It was reported that sometimes the NOC shift only had 1 staff in the Assisted Living floors, and 2 staff in the Memory Care unit, but at times 1 Memory Care staff has to be pulled to help the Assisted Living floors. Per document review, the findings indicate that facility caregiver staff have been working 12-hour shifts since at least November 2021, and has been using a total of 15 registry staff as a result of staffing shortages. Staff scheduling documents indicated that the Administrator and Wellness Director were scheduled to work as caregivers on at least 2 different dates. Per staff interviews, residents are to be showered a minimum of twice weekly. Allegation: Staff does not provide proper meal service to residents in care. It is alleged that staff are delivering the meals late to residents, the food is cold, and residents that require feeding assistance are awaiting at least 40 minutes after food is delivered to receive assistance from staff. Based on document review, the findings indicate that there are 5 residents that require feeding assistance. Three (3) out of seven (7) residents stated that their food has been delivered late. Per staff interviews, meals were being provided to residents in their rooms as a result of a COVID-19 virus outbreak. On 2/14/2022, residents resumed dining services in th e dining room. Administration staff stated that residents that require feeding assistance take approximately 30 minutes - 1 hour for meal consumption. Five (5) out of seven (7) staff stated that it is taking staff at least 30 minutes to go feed the residents that require assistance, because they are busy attending other resident needs. It was reported that on Sunday February 13, 2022, staff began passing breakfast meals at 9:15 am, and they finished at about 10:00 AM. The residents that needed assistance began eating their breakfast until past 10:00 AM, and on that day staff began serving lunch at an earlier time in order for lunch service to be on time. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are being cited. Exit interview was conducted and a copy of the report and appeal rights were issued.

Licensing Program Analyst (LPA) Galarza conducted an unannounced Annual Continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Diana Bautista. The facility serves residents ages 59 and older. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is still in place at the front desk. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirements: An Infection Control Plan has been added to the Plan of Operation. The facility has a Dementia Waiver in place and an approved Hospice Waiver for 20 residents. There are presently 23 residents enrolled in hospice care, which exceeds the approved waiver. Citation was issued. A fire clearance for 114 non-ambulatory residents; of which 15 may be bedridden is in place. There are 4 bedridden residents in care. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 6/2/2024. No Surety bond is in place. Facility does not handle resident monies. ***Narrative continues next page.***** 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 Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. The facility is a three (3) story building consisting of 77 resident rooms. The 1st floor consists of a lobby, dining room with outdoor courtyard, kitchen, medication room, administrative offices, electrical room, public restrooms, laundry room, 21 resident rooms, shaded outdoor courtyard area, and a Memory Care unit with multi-purpose room, and outdoor courtyard. The 2nd floor consists of 28 resident rooms, Bistro area, game room, public restrooms, 2 storage rooms, laundry/housekeeping room, outdoor shaded balcony area, and 2 common areas. The 3rd floor consists of 28 resident rooms, fitness room, theater room, lounge, beauty shop, and outdoor shaded balcony area. Delayed egress is in place in the 1st floor Memory Care unit. There are evacuation chairs on 2nd and 3rd floor stairwells to be used during an emergency as a path of egress from the facility to safety. On 7/24/2023, an annual fire inspection was conducted by Code Red Fire, Inc. The sprinkler system, alarms, fire connections, water flow alarms were inspected. The facility has fully charged fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Beds in rooms 107, 110, 115, 218 did not have mattress pads. Citation was issued. Staffing: A total of 49 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 8/15/2024. Staff have criminal background clearance and training, with exception of staff (S1). Citation was issued. Ten (10) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was reviewed. Staff (S2-S6) did not have current 1st/Aid certificates. ***See next page. 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 Resident Records/Incident Reports: A total of 10 resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, Individual Service Plans, and medication records. NOTE: Previous licensee's admission agreements are being used. Citation was issued. RCFE complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the entrance area. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Eleven (11) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medication errors were observed on 12/5/23, citations were issued. Medical and dental transportation is not provided at this time because the facility does not have staff/driver. Per Plan of Operation the facility shall provide transportation. Citation was issued. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Evacuation chairs in each floor were observed. Records of resident Appraisal and Needs services plans are part of Emergency training. *****See next page. 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 Health Needs: Twenty three (23) residents are receiving hospice services, which exceed the approved waiver total of 20 residents. Five (5) residents receive home health services. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in some resident rooms. Full rails were observed in hospice residents. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were issued.

Licensing Program Analysts (LPA) Galarza and Sanjay Vaid conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Business Office Manager Andrea Lopez. Administrator Diana Bautista arrived later. During today's visit the following was completed: LPAs toured the interior and exterior physical plant. All common areas, activity rooms, common bathrooms, kitchen, dining room, 20 resident rooms, med-tech room, and laundry rooms were inspected. The Memory Care Unit had an unlocked drawer with 2 pairs of scissors and sharp office supplies. Citation was issued. Review of medications and Medication Administration Records were reviewed. A total of 11 medication records were reviewed. Residents (R1 & R2) did not have PRN medications at the facility. Citation was issued. A total of 4 resident files were reviewed. Upon return LPA will finish reviewing resident files, and will review all staff files. One (1) resident was interviewed. Other resident interviews and staff interviews are pending. Due to time constraints, an annual continuation visit will be conducted at a future date. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were issued.

Allegation: Facility staff stole resident's money. According to information received Activities Director/Staff (S1) took $10.00 from resident (R1) last week with the purpose of buying Poweball and Mega Millions lottery tickets. As of October 10, 2023, staff (S1) had not given the resident the lottery tickets, and has not been seen working at the facility. It is suspected that staff (S1) was fired as a result of the theft. A total of six (6) staff were interviewed. None of the staff had suspicions that Activities Director stole money and/or personal belongings from residents. However, yesterday a staff person was approached by resident (R2) asking for Activities Director, and reported to staff that the resident gave a silver necklace that needed it repairs to staff (S1). Resident (R2) stated that the silver necklace had not been returned until today. Staff (S1) was not able to repair the necklace, but had forgotten to return it to R2. The approximate worth of the necklace was $40 dollars. A total of nine (9) residents were interviewed. Only resident (R1) reported that S1 took money from the resident. Staff (S1) stated that when resident (R1) asked them to buy lotto tickets they told the resident "No", but the resident insisted and staff took the money. Staff (S1) stated that they have not worked at the facility in over 1 week and had not had a chance to bring the lotto ticket, or returned the resident's phone calls. Administrator reported that staff (S1) is being terminated from employment today because they did not call or show up to work 3 scheduled days. The termination is not related to the allegation, because Administration staff learned about the allegation after the decision to terminate was made. Per facility Personal Property Procedures, documentation of resident Theft and Loss Record was completed. However, a police report was not filed because the value of the loss was $10; not more than $100.00. Staff (S1) stated they plan to drop off the tickets sometime this week. As of today resident (R1) has not been given the lotto tickets that were purchased last week by staff (S1). Therefore, there is sufficient evidence to corroborate the allegation. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.