Lake Park Senior Living

Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by: Based on observation and record review, licensee did not comply with the section cited above by having elevator #2 in disrepair which poses a potential health and safety risk to the persons in care.

87303 Maintenance and Operation(a) The facility shall be ...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:Based on observation the Licensee did not comply with the section cited above in having elevator in disrepair, which posed an immediate health and safety risk to persons in care.

87303 Maintenance and Operation(a) The facility shall be ...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on observation and records, Elevator two has been inopeerational since November.

(a) In addition to the rights listed in Section 87468.1... (1) To have a reasonable level of personal privacy in accommodations... personal care... This requirement was not met as evidence by: Based on interviews and record review the Licensee did not comply with the section cited above in giving resident peronal privacy which poses a potential health and safety risk to person in care.

(a) In addition to the rights listed in Section 87468.1... the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days... This requirement was not met as evidence. Based on observation and interview the Licensee did not comply with the section cited above in providing prompt access to resident's responsible party, which poses a potential health and safety risk to persons in care.

The licensee shall have a financial plan that … assures sufficient resources to meet operating costs for care of residents…” Based on investigation, licensee did not comply with the section cited above by receiving several past due notices for PG&E (dates 11/29/23 thru 01/30/24), Waste Management (dates 02/14/23 thru 01/10/24; and per W1, contractor has not been paid for work performed.

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or rel...ing, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:Based on interviews and file reviews, the licensee did not comply with the section cited above in not ensuring staff training's are current which poses an immediate health and safety risk to persons in care.

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....Additional staff shall be employed as necessary to perform office work,...buildings..... and grounds...... Based on interviews and record review the licensee did not comply with the section above for not having sufficient staff to meet residents' needs such as assistance with 2 person transfers, diapering needs during NOC shift, which posed potential health and personal rights risks to persons in care.

(a) Residents of residential care facilities for the elderly shall have all of the following rights:This requirement was not met as evidenced by: Based on observation and interviews from investigation the facility was not monitoring individuals coming into the facility or requiring them to sign in which posed a potential safety and personal rights risk to residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, .....residents in privately operated residential care facilities for the elderly shall have all of the following personal rights.... No dificiency cited

“…Any significant changes in the plan of operation…shall be submitted to the licensing agency for approval.This requirement is not met as evidenced by: Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety or personal rights risk to persons in care.

§1793.2(s)“…the Department, in its discretion, may condition, suspend, or revoke any…certificate of authority issued under this chapter if it finds that the applicant or provider has done any of the following: (s) Failed to fulfill his or her obligations under continuing care contracts.”This requirement is not met as evidenced by: Based on observations, interviews and record reviews, the licensee did not comply with the section cited above by not providing adequate 24-hour security as specified in existing CCRC contracts – with adherence to existing CCRC contracts being a condition of terms of sale by the California Department of Justice, which poses a potential health, safety or personal rights risk to persons in care.

87305 Alterations to Existing Building or New Facilities(a) Prior to construction or alterations, all facilities shall obtain a building permit.This requirement was not met as evidenced by: Based on observation and interviews, the Licensee did not comply with the section cited above by getting a building permit before doing alterations in kitchen, which poses a potential health and safety risk to residents in care.

87755 Inspection Authority of the Licensing Agency(b) The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility. Based on record review, the licensee did not comply with the section cited above by providing requested account documents for utilities, vendors accounts and status of outstanding payments which poses an immediate health and safety risk to persons in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidenced by: Based on observation and interviews, the Licensee had not repaired the front door for over a month and the basement door for more than four months, which poses a potential health and safety risk to residents in care.

Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios ... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.This requirement was not met as evidence by: Based on the lack of proof that quarterly emergency drills are being conducted, and statements from both residents and staff members that they have not been occurring, the licensee has not been complying with the section cited above.

ARTICLE 7.5. Resident Participation in Decisionmaking [1569.80- 1569.80.]This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above...On 3/20/2023 LPA KN interviewed the Administrator, who stated that the facility had informed the RP of a need for a 24 hour 1:1 aide. LPA found that the facility did not issue an advance 30-day written notice of a new need and the associated costs – as required.

Health & Safety Code (H&SC) 1793.21(t)The department, in its discretion, may condition, suspend, or revoke any permit to accept deposits, provisional certificate of authority, or certificate of authority issued under this chapter if it finds that the applicant or provider has done any of the following:(t) Made material misrepresentations to depositors, prospective residents, or residents of a continuing care retirement community.This requirement was not met as evidence by: Based on interviewed:A resident who lived in a residential living units (RLUs) needed to move to an Assisted Living Units (ALU) and was being to asked to sign new Residence & Care Agreements even though the original agreement with Methodist was in effect and that agreement did not require residents to sign a new admission agreements when moving to an ALU. This resident was housed in a temporary ALU and he and his family were told by the ED that he would not be moved to a permanent unit until a new agreement was signed.

1793.219(s).The department, in its discretion, may condition, suspend, or revoke any permit to accept deposits, provisional certificate of authority, or certificate of authority issued under this chapter if it finds that the applicant or provider has done any of the following:(s) Failed to fulfill his or her obligations under continuing care contracts.This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above...LPA reviewed the originating CCRC contract and observed that it stated that residents who develop memory care conditions would be retained by the facility. LPA obtained a copy of letter to R1, dated 3/12/23, whereby R1 was being evicted as the facility does not accept or retain memory care residents. On 3/20/23, LPA interviewed the Administrator who confirmed that the eviction letter was issued to R1 and that the family needed to hire/pay for an outside 1:1 aide. It was further found that per the terms of the sale of the business, the current Licensee/facility is to adhere to existing contracts agreed upon with the previous Licensee.

Complainant alleges that the Provider stopped providing security personnel as provided in the Residence and Services Agreement which was a violation of Health & Safety Code (H&SC) §1793.21(s) which states that Provider “Failed to fulfill his or her obligations under continuing care contracts.”.This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above...The interviews were held as listed above. The following documents were reviewed:• February 28, 2023 email from ED to residents• Front Desk calendar for March 2023• Approved Residence and Services Agreements from Methodist Homes and Lake Park Senior Living

Complainant alleges that the Provider’s food service is insufficient and in violation of Health & Safety Code (H&SC) §1771.8(s)(a) which states that Provider “Failed to fulfill his or her obligations under continuing care contracts.”This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above...AGPA JW found that the facility had changed and eliminated components of the food service without providing at least 30 days written notice, and that the Licensee Provider had not held a meeting 60 days prior to adjustments in “policies, programs, or services that would materially change the operation or environment of the community as required by the Health & Safety Code and CCRC requirements.”

Health & Safety Code (H&SC) §1793.21(c)(2) which states residents shall have a right “To live in anenvironment that enhances personal dignity, maintains independence, and encourages self-determination.This requirement was not met as evidence by: The interviews were held as listed above. The following documents were reviewed:• Approved Residence and Services Agreements from Methodist Homes and Lake Park Senior LivingBased on interviews with the residents during the December 29, 2022 Town Hall meeting and on separate occasions the ED at the time informed residents that the community was not a continuing Care Retirement community.