Complaint·October 6, 2023

The investigation revealed the following… regarding the allegation: Facility did not follow Covid-19 protocols. It’s being alleged “the facility had Covid-19 cases that were not reported to the proper agencies, the facility refused to test staff and residents, stop visitation and enforce masking for outside visitors.” LPA interviewed 7 out of 75 residents in total. 1 out of 7 residents confirm the allegation. During interviews with staff, LPA interviewed 7 out of 70 in total. 1 out of 7 confirm this allegation. During a record review on 12/02/2022, after receiving information of a possible Covid-19 outbreak, LPA Agard contacted the facility regarding the allegation. At that time, the acting Administrator confirmed there had been positive Covid-19 cases that were not reported to Community Care Licensing. On 12/02/2022, LPA Agard completed a Covid-19 intake for 3 Residents and 3 Associates. Regarding the allegation: Facility is in disrepair. It’s being alleged that the facility has incomplete wiring in some apartments, lifters in the patio that are loose, leaks in the building, and elevators not running on various occasions. 0 out of 7 residents were able to confirm the allegation. During interviews with staff, 5 out of 7 confirmed this allegation. S2 states, “not being aware of any leaks or wires being exposed. All the elevators are working. The patio is up for repair.” During a facility tour on 12/05/2022 and 01/11/2023, LPA observed the lifters in the center of the courtyard to be caving inward. This section is identified by tape and small safety cones. Based on the interviews with staff and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated . California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D. Licensing Program Analyst (LPA) David España conducted an exit interview and a hard copy was provided with appeal rights to Lilit E. Mnatsakanyan, Administrator. See LIC 9099-D on the next page Regarding the allegation: Facility does not have an emergency disaster plan. It’s being alleged the community may not have an emergency binder in place. Staff or residents may not know what the procedures are during an Emergency.” 2 out of 7 residents confirm the allegation. All residents unanimously agree that they are unaware if the facility has a physical hard copy of a disaster plan, but 5 residents confirmed being trained on what to do in the event of an emergency. During interviews with staff, 1 out of 7 confirmed this allegation. During a record review, LPA Agard reviewed and confirmed facility’s disaster plan. Regarding the allegation: Facility does not provide a safe environment for residents. It’s being alleged “the community has no security during the day and there have been various occasions homeless have entered the community putting the residents in danger.” 0 out of 7 residents confirmed the allegation. Residents denied feeling unsafe and reported there is a security guard outside at nighttime. During interviews with staff, 1 out of 7 confirmed this allegation. S2 states, there is concierge 24/7 and security from 7pm-7am. Regarding the allegation: Facility staff is not following safe food handling practices. It’s being alleged the kitchen prepares and distributes/serves meals without wearing gloves or hair nets.” 0 out of 7 residents confirm the allegation. Residents reported no safety concerns with the way their food is being handled. During interviews with staff, 1 out of 7 confirmed this allegation. During a visit on 12/05/2021 and 01/11/2023, LPA observed kitchen staff wearing gloves, a hairnet or chef’s hat. Regarding the allegation: Facility staff does not maintain accurate resident paperwork. It’s being alleged “residents are allowed to move in without their paperwork being complete.” 0 out of 7 residents confirm the allegation. All residents interviewed unanimously agreed not being aware of the specifics of this allegation and assume the facility has all the necessary paperwork for their file. During interviews with staff, 2 out of 7 confirm this allegation. During a visit on 12/05/2021 and 01/11/2023, LPA conducted a sample record review of resident files and found no records missing. Based on LPA’s observation, interviews conducted, and record review , the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated. Licensing Program Analyst (LPA) David España conducted an exit interview and a hard copy of the report was provided with appeal rights to Lilit E. Mnatsakanyan, Administrator.