Pasadena Villa Senior Living

87303(a) 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 is not met as evidenced by:sliding door in room 7B was broken on 2/28/2026 the glass has not been replaced. The door is currently covered with cardboard through the inside and a plywood sheet on the outside which poses a potential health and safety risk for residents in care.

Based on observation, the licensee did not comply with the section cited above in that water temperature readings in Room #s 9 (124.1 deg F), 13 (122.1 deg F), 34 (132.6 deg F), 40 (127.2 deg F), and 46 (129.5 deg F) did not measure within the required 105 - 120 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to residents in care.

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: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by: Based on investigation conducted by Investigation Bureau, it was determined that facility’s neglect/lack of supervision and additional measures, allowed R2 to make unwanted physical advances toward R1 and other female residents which poses an immediate risk to the health, safety, or personal rights to residents in care.

87463 Reappraisals...(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition....(1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to:..This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which a re-appraisal to assess R1’s condition was not completed which poses a potential health, safety or personal rights risk to residents in care.

87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports..(1) A written report... for the resident within seven days of the occurrence of any of the events specified...report shall include the resident's name, age, sex and date of admission; date and nature of event;....(D) Any incident which threatens the welfare, safety or health of any resident.....This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which R1's unwitnessed fall incidents that happened on 08/10/2025, 08/11/2025 and 08/28/2025, resulting in injuries and hospitalization were not submitted and faxed to CCL which poses a potential health, safety or personal rights risk to residents in care.

(a) The licensee shall ensure an adequate theft and loss program.....(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property ....The licensee shall.... made reasonable efforts to safeguard resident property ...... to meet each requirement specified in Section 1569.153.This requirement is not met as evidenced by: Based on interviews, Licensee failed to safeguard residents property during the relocation due to fire which poses a potential Health, Safety, and Personal Risk to residents in care.

Based on observation, the licensee did not comply with the section cited above in that (3) of the rooms (#4, #37 & #39) tested for hot water measured 122.8-123 deg F. The other rooms readings vary between 84 deg F to 122 deg F which poses an immediate health, safety or personal rights risk to residents 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. The licensee did not met this requirement as evidenced by: the licensee did not ensure staff was sufficicient in numbers to prevent residents from accessing the facility while the facility is under renovations and repairs. This poses a potiential risk to the health, safety or personal rights of persons in care.

87217 Safeguards for Resident Cash, Personal Property, and Valuables-(b)Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement was not met as evidenced by: Staff did not properly cover and safeguard residents personal belongings during renovations and repairs. This poses a potiential risk to the health, safety or personal rights of persons in care.

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may

Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources.This requirement was not met as evidenced by: Staff did not properly cover residents personal belongings during renovations and repairs.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: Based on observation and interviews, the Administrator did not comply with the section cited above in which LPAs observed the dining room's air conditioning is inoperable and the ice machine is broken which poses potential health, safety or personal rights risks to residents in care.

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents for personal care.... shall deliver hot water. Hot water temperature controls shall be maintained... to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).This requirement is not met as evidenced by: Based on interviews and observation, the hot water temperature readings during the visit on 5/21/2024 were 90.8 deg F in stall #1, 98.6 deg F in stall #2 and 89.2 deg F in stall #3, all stalls were in the large community shower room which poses an immediate health and safety risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirment is not met evidence by:During IB interview with R2 it was stated that R2 had been without a room for 2-3 days. This was confirmed by S4 who found R1 sleeping on the floor and S1 also confirmed that the two residents were having issues, and S1 was working on getting R2 a new room. IB also observed R2 with a few bags in the facility hallway.

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.This requirment is not met evidence by: Based on IB's investigation it was determined that there were inconsistent/false statements from staff about R1's injuries and who arranged medical transportation for R1, the SIR states staff arranged transportation, however, records reveal that R1 911 for help and to be transported to hospital for further treatment.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)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. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirment is not met evidence by:IB discovered there was an incident that occurred where S1 was involved in a physical altercation with R1's family member and sustained injuries to their eye during the altercation, an incident report was not filed for this incident and police was called.

Based on observation, the licensee did not comply with the section cited above in that LPAs observed that the faucet in Room #19 was broken, no water coming out on cold water side, and the bathroom sink in Room #18 was clogged which poses an immediate health, safety or personal rights risk to residents in care.

Based on interview, record review, the licensee did not comply with the section cited above in that there is no current and valid Administrator certificate on file which poses/posed a potential health, safety or personal rights risk to residents in care.

Based on observation, the licensee did not comply with the section cited above in that water temperature readings in Room #s 11 (124.5 deg F), 33 (134.9 deg F) and 34 (131.3 deg F) did not measure within the required 105 - 120 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to residents in care.LPAs observed that the faucet in Room #19 was broken, no water coming out on cold water side, and the bathroom sink in Room #18 was clogged which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.This requirement is not met as evidenced by: R1 needing medical attention after sustaining injuries to the right hand and index finger that had redness, swelling, and drainage as a result of an unwitnessed slip and fall, R1 called emergency transportation for treatment themselves on 12/26/23.

87506 Resident Records...(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff...This requirement is not met as evidenced by: Based on interviews and review of documentation, R1's Medication Administration Record (MAR) for March 2024 is inaccurate. MAR for March 2024 shows that 2 staff initialed the medication log from 3/12/2024-3/16/2024 even after R1’s passing which posed an immediate health and safety risk to residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...care facilities ... shall... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are ...to meet their needs.This requirement is not met as evidence by: Based on documents review licensee did not ensure R1 did not leave the facility unassisted which resulted on a fall which poses an immediate risk to the health,safety, or personal rights of the person in care. *Immediate civil penalities assess for $500.00*

General Food Service Requirements(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. There is sufficient evidence to support that the facility has a cockroach issue.

Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. The soda machine dispenser spout has an unknown residue stuck and needs either deep cleaning or replacement.

Night Supervision(a)The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with....planned emergency procedures, shall be trained in first aid..., Incidental Medical and Dental Care Services and shall be available as indicated below to assist in caring for residents in the event of an emergency. The requirement was not met as evidenced by:LPA reviewed R1, R2, R4 R5 in-service alongside with Staff #1(S1) and there were no identifier's showing nocturnal shift provided care and supervision to resident(s). Interviews with (3) out of (5) staff stated residents were being aware of issues with noc shift caring for residents. Interviews with residents (4) of (5) informed LPA night shift staff were not assisting/ responding to residents to provide care and supervision .

87211 Reporting Requirements: (1)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.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. The requiement was not met as evidenced: LPA tried to request R1's incident reports for the month of Dec 2023, but staff reported they do not have any access on it and LPA was not able to obtain any incident reports during the complaint visit.

87618 Oxygen Administration-Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (H) Equipment shall be operable. The requirement was not met as evidenced by a witness observed R1 oxygen tanks were not filled and R1 had oxygen which posed a immediate risk to residents in care.

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. This standard is not met at evidence by: "staff admitted that there was a history prior to the incident that showed R-2 may have needed a higher level of care. Interviews of staff, residents and Investigator observations revealed that there was a lack of available staff and staff response when requested. There is sufficient evidence to support the allegation of lack of supervision resulted in R-2 sustaining injury”.

87303 (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water (...) to attain a temperature of not less than 105 degree F and not more than 120 degree F.This requirement is not met as evidenced by: Based on interviews and observation, LPA determined that the hot water temperature in the facility fell below the 105 degree threshold in Rooms 3, 7, and 18, which poses a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care...(c) ...resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2)..the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on interviews and review of documentation, R1's Medication Administration Record (MAR) for Sep. 2020, no medication was given to R1 to help alleviate his severe pain and fever except on 9/20/2020 and 9/21/2020 only which posed an immediate health and safety risk to residents in care.

87303 Maintenance and Operation: (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more ... buildings shall have a signal system which shall:This requirement is not met as evidence by: Based on observation and interviews licensee failed to ensure residents had a signal system in place which poses a potential risk to the health, safety, or personal rights to the persons in care.

Personnel Requirements – General.Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement is not being met as evidenced by: Interviews conducted confirmed that during the month of October 2022, Staff 2 (S2) was a “no-show” multiple times, leaving only one caregiver on duty during the overnight shift, between the hours of 10:30pm – 6:30am. Statements obtained confirmed that overnight staff were observed in the office area most of the time, sitting or sleeping and not doing rounds every two hours and checking on the residents. It was reported that overnight staff would at times ignore the residents call for help and when staff did respond, residents waited 2 or more hours before receiving assistance. This poses a potential health, safety or personal rights risk to persons in care.

Managed Incontinence.In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not being met as evidenced by:Statements obtained from residents and staff corroborated that caregivers were not doing diaper changes during the overnight shift and/or changing soiled resident beddings and morning staff would often times find incontinent residents laying in bed, wet and soiled for hours. This poses a potential health, safety or personal rights risk to persons in care.

Personnel Requirements – GeneralAll RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.This requirement is not being met as evidenced by: Statements obtained from staff and residents stated that S4, who works in the kitchen, will often times assist residents with care. After reviewing the file of S4, LPA observed that S4 does not have the required training to provide resident care, such as assisting with showers, changing and providing incontinence care. This poses a potential health, safety or personal rights risk to persons in care.

Personnel Requirements – GeneralStaff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not being met as evidenced by: During the visit conducted on 10/20/22, LPA reviewed the file of S1 and observed that the CPR/First Aid Certificate for S1 expired on April 30, 2022. This poses a potential health, safety or personal rights risk to persons in care.

Personal Rights of Residents in All Facilities.Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by:On 9/7/22, at approximately 12:40pm, S1 was overheard by witnesses yelling at R1 in a humiliating and intimidating manner. This poses a potential health, safety or personal rights risk to persons in care.

Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:(A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. This requirement is not being met as evidenced by:During today's visit, LPA and AGPA toured the facility and observed that the facility did not have a functional signal system in all resident rooms, for all residents. This poses a potential health, safety or personal rights risk to persons in care.

Maintenance and Operation.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 is not being met as evidenced by: During the tour, the LPA and AGPA also observed Room #16 to be unsanitary. The room was dirty, the floors had stains and were sticky and there was debris/trash on the floor of the living area and also the bathroom. This poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in during visit LPA was not provided a copy of surety bond which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in last fire drill conducted for each shift was conducted on 12/20/22, 2/22/23, and 2/23/23 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in review of P&I money showed R2 should have a balance of $70 per log and there was no money on envelope and R8's balance was not tracked on log which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 resident's medication reviewed were missing 1 or more medications and medication sheet was initialed and provided to residents in care; R1,R2,R4 which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in observation of medication for resident was observed on top of the bed frame in shared bedroom #4 which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 3 residents have full bed or half bed rails and a physician's request is not on file which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in medication for R4 was observed outside original labeled package which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in emergency disaster plan LIC 610D reviewed did not have date of last update or review which poses/posed a potential health, safety or personal rights risk to persons in care.

Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility. The requirement is not met as evidenced by: Based on interviews conducted, LPA discovered that R1 was unlawfully evicted from the facility and an eviction notice was never issued to R1. Statements obtained from the Assistant Administrator and R1 corroborated that R1 was not allowed back at the facility after being hospitalized on 5/2/23. R1 is no longer residing at Pasadena Villa Senior Living.

Based on observation, the licensee did not comply with the section cited above in kitchen/dining/library floors were observed dirty with crumbs, laundry room has water damage, restroom by room #23 has mold in cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in 2 shower rooms observed by room #23 and across room #12 did not have skid mats which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in Med-Tech does not have a health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in water temperature tested in resident's room #28 tested at 121.6 degrees F., #40 tested at 120.7 degrees F., and #14 tested at 97.1 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in trash can used to dispose of diapers, liner, and human waste lid was open during tour which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in Administrator and Med-Tech do not have a TB test results on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based onrecord review, the licensee did not comply with the section cited above in R5 does not have a TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in Med-Tech - staff #5 does not have hours of shadowing for medication training and initial training is not signed which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in moldy and rotten produce (cabbage, brussel sprouts, and apples) were observed in the walking refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in kitchen floors were observed dirty, stove had grease with dust attached to it, trays were observed with grease and burn leftovers, and oatmeal bag was observed open which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in R1 adn R2 do not have a signed admision agreement which poses/posed a potential health, safety or personal rights risk to persons in care.

87459 Functional Capabilities ...(a) The facility shall assess ....personal assistance and care ... to perform specified activities of daily living...(5) Continence, including: (B) Whether assistive devices...catheter are used.This requirement is not met as evidenced by: Based on observation, interviews, records review, the Administrator did not comply with the section cited above in that R1's need for personal assistance and care was not met as R1 was observed in by EMS, “urine in the foley to be dark in color and cloudy” which posed a potential health and safety risk to residents in care.

87466Observation of the Resident..The licensee shall ensure...observed for changes in physical, mental, ...functioning ....appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented...resident's responsible person, if any. This requirement is not met as evidenced by: Based on observation, interviews, records review, the Administrator did not comply with the section cited above in that the condition that the resident was observed in by EMS, “urine in the foley to be dark in color and cloudy”, “EMS observed rigidity, pain, distension, and tenderness in all four quadrants” and “R1 was weak and in severe discomfort with a pain level 10 out of 10 and nausea level 8 out of 10" which posed a potential health and safety risk to residents in care.

87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.The requirement is not met as evidenced by: Based on interviews conducted: LPA observed food quality for perishable foods (vegetables and fruits) containing bacteria, fungus and mold. Food in unsanitary conditions for residents 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 is not met as evidenced by: Based on interviews conducted, the back door switch to the smoking area was in disrepair which poses a potential personal rights risk to residents in care.

Infection Control Requirements. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.This requirement is not met as evidenced by:At 9:30am, LPA was greeted by Staff #1 (S1) inside the facility (by the front door) and S1 was observed not wearing a face covering/mask, while working inside the facility. Also, upon entering the facility and walking inside the office area, LPA observed the Assistant Administrator / Alexander Solorio and Staff #2 also not wearing a face covering/mask, while working inside the facility. During today's visit, LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care.

Personal Rights of Residents in All Facilities.Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.The requirement is not met as evidenced by: Based on interviews conducted, the majority of statements obtained were consistent and corroborated with the allegation. Residents confirmed that linens and bed sheets are not changed regularly and often times residents have to request for their linens to be washed/changed because staff will not change them. There have been times where residents linens and bed sheets have not been changed for more than two weeks. During today's visit, LPA toured a random selection of resident rooms and observed the linens in rooms 33, 34B, 38B and 36B were soiled/dirty. Blood stains were observed on the linens in rooms 34B and 38B and on the pillow case in room 33. The pillow case in room 36B was torn and covered in stains.

Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities... To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. The requirement is not met as evidenced by; Residents and staff interviewed confirmed that the fire doors that exit to the back patio are too heavy for residents in wheelchairs to open. Often times, residents will wait on staff to come and open the doors for them because they are unable to keep the door open and wheel themselves out at the same time. During today's visit, LPA tried opening the fire doors that exit to the back patio and observed the weight of the doors and based on LPA's observation, it would be very difficult for anyone in a wheel chair to hold the door open and wheel themselves out at the same time.

Reporting Requirements. 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. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by;On 7/17/22, at approximately 5:50pm, there was an incident involving R1. S1 noticed R1 was smoking marijuana and drinking beer in the designated smoking area (back end of the facility). S1 also noticed a bag containing additional marijuana on top of the table, where R1 was sitting. S1 confiscated the bag containing the marijuana and locked it in the front office and reported the incident to facility management. The Pasadena Police Department was involved and conducted a visit on 7/18/22.

87415(a)(2) - Night Supervision(a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m....shall be available... to assist in caring for residents.(2)In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake.... This requirement was not met as evidenced by: LPA's interviews with staff revealed that there was a staff not responding to the call light. This poses a potential health and safety risk to residents in care

Oxygen Administration - Gas and Liquid. Smoking shall be prohibited where oxygen is in use.This requirement is not being met as evidenced by:Residents 1 and 2 require the use of oxygen administration and are able to administer oxygen on their own. On multiple occassions, R1 was observed by multiple staff and residents lighting up cigarettes inside her room, while oxygen is in use. This poses an immediate health, safety or personal rights risk to persons in care.

Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident... Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times...Based on majority of the interviews conducted the statements obtained were consistent and corroborated with the allegation. At 11:35am, LPA toured the facility and inspected the linen closets and laundry room and observed a low supply of bath towels for 53 residents.

Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents.The requirement is not met as evidenced by; On 1/1/22, at approximately 8am, R1 eloped from the facility in her wheelchair. From the interviews conducted, LPA learned that on the weekends, the front desk staff does not begin their work shift until 9am and there is no staff monitoring the front desk area and resident traffic going in and out of the facility between the hours of 6:30am and 9am. Per R1's Physician's Report, R1 is not able to leave the facility unassisted. This poses an immediate health and safety risk to R1.

Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents.The requirement is not met as evidenced by; On 3/7/22, R1 is observed (in surveillance video at 4:17pm) leaving the facility through the front door without staff supervision. Facility staff did not witness R1 leaving the facility and it wasn't until later, while conducting room checks when staff discovered R1 had eloped. Per the physician's report dated 3/1/22, R1 is not able to leave the facility unassisted. This poses an immediate health and safety risk to R1.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...following personal right (14)To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility. The requirement is not met as evidenced by LPA's observation and interviews by residents and reported the doors are not easy access for the residents use wheelchairs to go through which pose an potential risk for residents in care.

Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.This requirement is not met as evidenced by; Based on interviews conducted and records reviewed, LPA discovered that R1's health began deteriorating around the end of December 2021 and beginning of January 2022. R1 was observed by staff and R2 (roommate) to be disoriented and paranoid. Due to a decline in health, R1 was often observed to be hallucinating. This poses a potential health and safety risk to R1.

Pre-Admission Appraisal - General. Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors.This requirement is not met as evidenced by: After reviewing the file of R1, it was observed that at the time of admission, facility staff did not conduct a proper assessment of R1 as the Care Assessment/Evaluation, Functional Assessment, Mental Status Questionnaire and the Resident Appraisal were incomplete. Most of the answers to the questions listed on the forms were left blank. This poses a potential health and safety risk to the residents in care.

Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.This requirement is not met as evidenced by: The Unusual Incident/Injury Reports were reviewed for R1 and it was determined that R1's behaviors changed between period April of 2021 through September of 2021 and facility staff did not update the Appraisal/Needs and Services Plan for R1 addressing the current changes. This poses a potential health and safety risk to the residents in care.

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by; During the visit conducted on 7/7/21, at 12:15PM, LPA Katrdzhyan toured the facility with the assistance of Assistant Administrator / Alexander Solorio and observed a strong odor of marijuana coming from the hallway, near the dining room area. Based on statements obtained, LPA learned that residents have been observed smoking marijuana in their rooms and the outside, near the courtyard area.

Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by:After reviewing the file of S1, LPA discovered that S1 did not have the qualifications and training to administer medications to residents. Interviews conducted corroborated with the information found in the file of S1.

1568.683 Eviction notices; reasons for eviction contents, service (a)... a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.This requirement is not met as evidenced by: The licensee did not ensure that the reasons for eviction for R1 was written on the eviction letter which poses a potential health, safety, and personal right risk to resident in care.

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.This requirement is not met as evidenced by: The licensee did not ensure that the Appraisal/Needs and Services Plan for R1 has been updated to address current behaviors which poses a potential health, safety, and personal rights risk to residents in care.

Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2 Health and Safety Code section 1569.2(c) provides: "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.This requirement is not met as evidenced by;On 7/27/21, at approximately 1PM, R1 left the facility through the side gate, located in the parking lot. Per the Physician's Report dated: 9/1/2020, R1 is not able to manage own treatment, medication and equipment. R1 is listed as non-ambulatory and needs assistance with most of his activities of daily living and R1 is not able to leave the facility unassisted. This presents an immediate health and safety concern for R1 as the facility was not able to provide care and supervision to meet the needs of R1.

Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not being met as evidenced by:During a complaint investigation conducted on 7/7/21, LPA discovered that Staff / Estephanie Karina Morales was employed and working at this facility prior to obtaining a California clearance or a criminal record exemption as required by the Department.

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: The requirement is not met as evidenced by: Upon reviewing the residents records it revealed the Appraisal/Needs and Services Plan had not been updated to reflect the residents medication non-compliance or/and change in behavior.

87224 Eviction Procedures (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). (4) If, after admission, it is determined that the resident has a need not previously identified... and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.The requirement is not met as evidenced by: Upon reviewing the 30 day eviction letter it was determined the resident was not verbally abuse rather yelling at staff and constantly expressing dissatisfaction with their care. The resident also has the right to refuse medication and can't be used a house rule.

87625 Managed Incontinence(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidence by: During interviews conducted with residents it revealed they are not changed often and are not being changed during the night. Per Assistant Administrator, there was no logging system before and have recently implemented a log to monitor the care.