complaint·January 9, 2024

The investigation revealed the following: Regarding allegation- Facility is not following the proper protocol for COVID-19. It is alleged that the facility is following COVID-19 procedures that are far stricter than any other guidance by requiring residents to isolate for 5 days any time they are out of the community, not allowing visitations in resident rooms, and requiring visitors to take a COVID test upon arrival. On 12/29/22, upon arrival to the facility, LPA Maldonado rang the bell at the gate to request entry and was unable to enter the gated community. LPA was questioned for vaccination status and/or to take a COVID test to be allowed entry by facility staff. LPA explained that the visit was a licensing visit and LPA had inspection authority, regardless. Facility staff then allowed LPA entry through the gate. LPA observed a note posted on the front door of the facility, indicating that only outside visitations were allowed, visitors were to have no physical contact with residents, scheduled visits were required, a negative COVID-19 test was required for entry, face masks were required for both residents and staff at all times, room visits with residents were not allowed, and visitors were not allowed to move about the facility anywhere at any time during said visits. LPA observed a resident in a wheelchair sitting in the lobby area wearing a mask below their chin. Administrator Fan walked up to the resident and without warning, pulled their mask up over their nose and mouth and told the resident to keep it on. At the time of LPA's initial visit, the requirement for requesting a negative COVID-19 test or vaccination status was no longer in place by the Licensing agency. LPA explained this to the Administrator, to which which she stated she still required this to keep residents safe as well as making an appointment prior to visiting. LPA explained that is a violation of resident's personal rights and could not be implemented as a requirement. During interviews with staff, (3) of (3) staff admitted to this allegation stating that they only want to keep residents safe from contracting COVID-19. LPA Maldonado asked Administrator Fan what the quarantine policy was. She admitted that any time a resident went out of the facility, they were required to quarantine/isolate in their room for (5) days to ensure the safety of others, regardless of whether there was possible exposure or they had symptoms. (5) of (5) residents interviewed corroborated the allegations, stating that no room visits are allowed, a 5-day isolation period is required any time they leave, and their visitations are required to be outside. Regarding allegation: Facility is not complying with the local health department's guidelines for COVID-19. It is alleged that the facility is only allowing resident visitors so long as they make an appointment prior to their visit and that the visit is only conducted outdoors, which is different than what the current visitation guidance was, set forth in the Los Angeles County Department of Public Health Guidance for Community Care Facilities , updated 11/10/2022 . After review of the LA County Department of Public Health visitation guidance, it was noted that indoor and outdoor visitation is allowed in green and yellow zones regardless of current outbreak status . (3) of (3) staff interviewed admitted to this facility policy/requirement, stating that they are trying to ensure residents health and safety to COVID-19. (5) of (5) residents interviewed corroborated the allegation stating that they can only receive their visitors outdoors, and by appointment only. (Report continued on LIC9099-C) Regarding allegation: Facility is violating residents' personal rights. It is alleged that the facility is not allowing visitors without appointments, is requiring residents to isolate for (5) days any time they leave the facility, are enforcing the isolation by restraining residents from leave by placing a stanchion cord across their room door, which is tied/clipped on both sides of the grab bars located outside their door, and not allowing private visits inside residents rooms, which are all violations of residents' personal rights. (3) of (3) staff interviewed admitted to this allegation, stating they are only trying to maintain residents safe from contracting COVID-19. (5) of (5) residents corroborated the allegation stating that while all this is true, they are okay with the requirements of the facility. LPA attempted to explain to both residents and staff that while residents and their families may be okay with this, the facility is violating residents' personal rights, as they are allowed to have visitations in their rooms, are not required to isolate, and cannot enforce the isolation by restraining them with the stanchion cord. Regarding allegation: Facility is not allowing visitors. It is alleged that that facility requires that visits must take place outside , that visitors without an appointment will be turned away at the gate , that visitors must test, and that bedridden residents will only be allowed visitation in case of emergency. (3) of (3) staff interviewed admitted to the allegation stating that they are only trying to maintain residents safe from contracting COVID-19. (5) of (5) residents corroborated the allegation stating that all of their visits must be outside, given their visitors made an appointment, otherwise the visit is not allowed. Based on LPAs observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D. An exit interview was conducted and a copy of this report and appeal rights were provided.