Office review·October 30, 2023

At 11:00 a.m. on 10/30/2023 an Informal Conference was held at the Woodland Hills-South Adult and Senior Care Regional Office. This Informal Conference was held to discuss a recent case management visit and to provide guidance to ensure future compliance. Prior to the meeting, Licensee was given the chance to review the facility file. Present at today's meeting were the following: · Ginger Po – Licensee/Administrator · Jeffrey Po – Licensee · Chris Salvador – Director of Operations/ Co-Administrator · Edgar Galang – Co-Administrator · Denise Isfeld – Legal Council for the facility · Angela Kendrick – Regional Manager (RM) · Naira Margaryan - Licensing Program Manager (LPM) · Nicholas Reed - Licensing Program Analyst (LPA) The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions. BRIEF HISTORY: The facility has been in operation since licensure on 02/03/2021. The facility is in good standing with the Department. On 09/29/2022, LPM Margaryan and LPA Reed conducted an unannounced case management visit in response to an incident report and death report submitted by the facility. The reports involved an alleged altercation between Resident #1 (R1) and Resident #2 (R2). Both residents requiring medical attention due to severe injuries. R1 experienced rib pain, and R2 was found bleeding and unresponsive and passed away days later at the hospital. Interviews, record review, and observations from the case management visit on 09/29/2023 revealed multiple concerning elements regarding the facility’s compliance to Title 22 and other regulations. LPA and LPM explained the concerns discovered during the case management visit on 09/29/2023: The proximity of the facility’s smoking balcony on the second floor to the activity room and resident rooms. At least one (01) resident was observed smoking in a bedroom. A deficiency is cited today for violation of 87464(f)(1) based on observations of LPA and LPM at approximately 12:00 p.m. on 09/29/2023. Insufficient care for R2 and Insufficient level of care for R1 and other residents experiencing problems with alcohol. R1’s physician’s report being unsigned. A deficiency is cited today for violation of 87458(a) based on record review at approximately 11:30 a.m. on 09/29/2023. LPM Margaryan discussed the stipulations of the ALWP requiring a microwave and television in a participating resident's room. The facility must maintain a waiver from the resident if they wish to forgo these requirements or live in a shared room. Jeffrey spoke of the amenity form where a resident waives their right to certain amenities. Chris Salvador presented documentation for R1 and R2 showing their Amenity Forms waiving their rights to a private room, refrigerator, and microwave. RM Kendrick requested a roster of residents participating in the ALWP be sent to LPA Reed. Licensee Ginger explained the ALW resident acceptance process. Chris noted the DHCS inspection for the ALWP took place approximately 2 - 4 months ago. LPM Margaryan and Co-Administrator Salvador discussed possible facility adjustments and collaboration with the Department of Health Care Services (DHCS) to comply with ALWP requirements. LPM Margaryan then discussed the licensee's responsibility to meet all residents' needs, including residents who have documented instances involving alcohol use. Counseling, verbal warnings, discussion, documentation, updating care plans, and all reasonable steps should be taken prior to considering eviction. LPM Margaryan then discussed observations from the Case Management visit on 09/29/2023 in which LPM observed a resident smoking inside of a resident room. Additionally, the second floor smoking balcony was determined to be too close to a resident's room. Co-Administrator Salvador addressed the smoking balcony history, along with the purpose for the second floor patio being accessible to second floor residents. All parties collaborated to determine a more appropriate location for residents to smoke, but a solution was not found today. Licensee Ginger discussed future plans for a portion of the second floor to be designated for the Memory Care unit. LPM Margaryan discussed the details of the plan to ensure proper supervision is afforded to residents. Chris mentioned the ongoing eviction process of Resident #3 (R3), and LPA and LPM confirmed to representatives the legality of the eviction. LPM Margaryan reiterated the importance of the completion and current status of all resident files, including but not limited to medical assessments, admission agreements, needs and service plans, and other necessary files. Especially important was updating the files of residents with histories of alcohol and substance abuse to ensure the facility is providing all necessary services for the residents' health and safety. Today, two (02) deficiencies are issued for violations discovered from the 09/29/2023 Case Management visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.