197607476-6-18-2020-28-AS-MVAO-BQUPBA-20200623110958

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607476
Report Date: 06/18/2020
Date Signed: 06/18/2020 11:46:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2019 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20190626104738

FACILITY NAME:	VISTA COVE AT ARCADIA		FACILITY NUMBER:	197607476
ADMINISTRATOR:	NOEMI BIELY		FACILITY TYPE:	740
ADDRESS:	601 SUNSET BOULEVARD		TELEPHONE:	(626) 447-0106
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY:	130	CENSUS: 74	DATE:	06/18/2020
		UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Noemi Biely		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility charging residents for services that are not rendered
Staff are not properly trained
Staff are under the influence of drugs and alcohol while providing care and supervision
Unqualified staff administering medications
Facility staff failed to maintain resident's records
Inadequate staffing to meet resident's needs
Staff failed to keep resident's files confidential
Staff failed to treat resident's with dignity and respect

INVESTIGATION FINDINGS:

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***This report serves as an amendment and supersedes the complaint investigation report created on 6/16/20. The complaint investigation findings have not been changed.***

Licensing Program Analyst (LPA) Alma Gonzalez initiated a telephonic subsequent complaint investigation to deliver investigation findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Noemi Biely.

Investigation consisted of the following: During the initial visit conducted on 7/3/19, LPA Gonzalez obtained a copy of Staff and Resident Rosters. LPA interviewed Administrator Noemi Biely. LPA reviewed Staff 1 (S1's) file. LPA conducted a tour of entire facility inside and out. LPA interviewed Karla Tapia (LVN),

(See LIC 9099C for continuation of report)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20190626104738

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA COVE AT ARCADIA	FACILITY NUMBER: 197607476
	VISIT DATE: 06/18/2020

NARRATIVE

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Angie Gil (Med Tech) and Cindy Bustillos (Resident Relations Coordinator). On 4/17/20, LPA Mary Flores conducted a telephone interview with Resident 1 (R1). On 4/20/20, LPA Mary Flores conducted phone interviews with R2-3. On 4/21/20, LPA Mary Flores conducted phone interviews with R4-5. On 4/23/20, LPA Mary Flores conducted phone interviews with R6-7. On 6/8/20, LPA Flores requested and received R1-7's Admissions Agreements and Physician’s Reports. On 6/12/20, LPA Gonzalez requested and received copies of Staff training and also received documents pertaining to S1. On 6/15/20, LPA Gonzalez called facility and interviewed the following staff by telephone: Director of Resident Services Vanessa Carrillo, Caregivers Florindah Wambua and Jocelyn Lopez.

The investigation revealed the following: In regard to allegation, Facility charging residents for services that are not rendered, it is alleged that facility administrator wrongfully charges residents for a higher level of care and does not provide higher level of care and facility administrator tells families that the residents are getting a higher level of care. It is also alleged that facility staff made false representations to families and residents to get them to move in. Families were told that the facility provides a full time nurse and an activities director but the facility did not have a nurse for several months. Interview conducted with Administrator Noemi Biely revealed that the facility is very fair in prices and does not charge for any services that a resident is not receiving. She stated that resident's families are very active and involved with the facility and the care of their loved ones. She stated that resident's admission agreements properly indicate what a resident is paying for and if they are paying for additional services it is properly itemized on their admissions agreements and properly initialized and signed by either the resident or their responsible party. Interviews with R1-5 and R7 revealed that they are aware of their monthly rate and are also aware of any additional charges that they pay for. LPA review of R1-7's admission agreements revealed that the residents are not being charged for services that they are not receiving. Based on LPA record review, interviews conducted with residents and staff there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Staff are not properly trained, it is alleged that medication was being given to residents incorrectly by untrained and unlicensed staff and that facility administrator would suggest putting new residents on hospice. It is also alleged that administrator refused to address serious mistakes being made by staff at the facility such as blood being taken from the wrong resident. Interview with Administrator Noemi Biely revealed that all staff at facility are properly trained. She stated that at no time is blood drawn from residents by facility staff. She stated that residents that require lab work will either be transported to the lab or

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20190626104738

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA COVE AT ARCADIA	FACILITY NUMBER: 197607476
	VISIT DATE: 06/18/2020

NARRATIVE

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some residents have their blood drawn at the facility by MS Diagnostics but never by facility staff. Ms. Biely also stated that she has never suggested putting any of the facility residents on hospice and that she knows that would never be possible as hospice is ordered by a doctor. Interview with facility staff revealed that they received proper training, have never drawn blood from residents or seen any other staff at facility draw blood from any resident at the facility. LPA review of copies of staff training documentation revealed that staff at facility receive proper training. Based on LPA record review, interviews conducted with facility staff there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Staff are under the influence of drugs and alcohol while providing care and supervision, it is alleged that there is alcohol and drug consumption by facility staff and management during work hours and that the facility has a doctor that regularly provides the staff with drugs for recreational use. Interview conducted with Administrator Noemi Biely revealed that the facility does not have a doctor on schedule and that residents are taken to their own private physicians. Administrator Biely stated that she would never allow such behavior at the facility. She stated that there are no staff or management staff at the facility that drink alcohol or do drugs. She stated that facility staff will randomly be tested for drugs and denies that any staff at the facility do any type of drugs. Interviews conducted with facility staff revealed that staff do not drink alcohol or consume any drugs. Facility staff stated that they are subjected to random drug tests and deny ever being under the influence of alcohol and/ or drugs while working at the facility or at all. Based on interviews conducted with facility staff there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Unqualified staff administering medications, it is alleged that the facility did not have a nurse for several months and medication was being given out incorrectly by untrained and unlicensed staff. Interview with Administrator Biely revealed that all staff at facility are properly trained. She stated that only Med Techs give out medication to residents. Administrator stated that the Med Techs are overseen by Director of Resident Services. She stated that there have not been any issues regarding medication being given out incorrectly by untrained and unlicensed staff. Administrator also stated that the facility has a nurse on schedule which is Director of Resident Services. Interview with Director of Resident Services Vanessa Carrillo revealed that she oversees the Med Techs and they are the only staff that hand out the medications to the residents. She stated that Med Techs are properly trained on Medication Management. Interviews with R4-7 revealed that their consists of medication distribution and that they are given their medications from Med

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20190626104738

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA COVE AT ARCADIA	FACILITY NUMBER: 197607476
	VISIT DATE: 06/18/2020

NARRATIVE

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Techs. Based on LPA review of staff training, interviews conducted with residents and staff there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility staff failed to maintain resident's records, it is alleged that facility staff regularly modified, destroyed and hid files when facility was audited by the state. Interview with Administrator Noemi Biely revealed that facility staff have never modified, destroyed or hid any files when being visited by Community Care Licensing (CCL). Administrator stated that files have always been available to CCL staff during annual inspections and other visits and she also stated that if a resident moves out or passes away the facility retains the file for three years as stated in Title 22. Interview with Resident Relations Coordinator Cindy Bustillos revealed that resident files are kept in the front reception office and are always available to CCL personnel. She stated that Staff files are kept separate from the residents files in a separate room that is located in a room inside the reception office. She stated that the staff files are locked but the key is available for staff to open the door and gain access to the files if CCL wants to review them. LPA Gonzalez toured the reception area and observed that resident files were located in the reception office and the staff files in a room inside the reception office. Staff Bustillos opened the door where the staff files are located. Based on LPA tour and observations and interviews conducted with facility staff there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Inadequate staffing to meet resident's needs, it is alleged that facility was understaffed many times for weeks, resulting in poor care, mistakes and hospitalization. Interview with Administrator Noemi Biely revealed that she ensures that the facility is properly staffed to meet the needs of the residents. She stated that facility staff provide good care to the residents and denies that the facility is understaffed which would cause staff to make mistakes that lead to resident's being hospitalized. She stated that residents are hospitalized at times but not due to the facility being understaffed. LPA's interviews with facility staff revealed that they believe there are enough staff on schedule to meet the resident's daily needs. Interviews with R1-7 revealed that staff meet their needs and they are satisfied with the services that they receive. LPA toured the facility and observed staff tending to residents throughout the facility and it appeared that there were enough staff on schedule to properly care for and tend to the residents. Based on LPA observations, interviews conducted with facility staff and residents there was not enough supportive evidence to concur with the reported allegation.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20190626104738

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA COVE AT ARCADIA	FACILITY NUMBER: 197607476
	VISIT DATE: 06/18/2020

NARRATIVE

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For the allegation, Staff failed to keep resident's files confidential, it is alleged that facility administrator would work with three of her close personal friends from hospice companies and allow them to go through resident files to see who they could put on hospice and facility administrator would receive kickbacks for such referrals and as a results residents were not getting the care that was promised or needed. Interview with Administrator Noemi Biely revealed that resident and staff files are always confidential and are stored in the facility reception office. She stated that the residents files are kept in the main reception area and the staff files are kept inside a room of the reception office. Administrator denies would the allegation of that she would work with three of her close personal friends from hospice companies and allow them to go through resident files to see who they could put on hospice. She stated that there is no way she could do that as a person has to be put on hospice by a doctor. Administrator denies ever receiving any kickbacks for such referrals and stated that facility residents receive the care that they deserve and pay for. Interview with Resident Relations Coordinator Cindy Bustillos revealed that resident files are kept in the front reception office and are always available to CCL personnel. She stated that Staff files are kept separate from the residents files in a separate room that is located in a room inside the reception office. She stated that the staff files are locked but the key is available for staff to open the door and gain access to the files if CCL wants to review them. She stated that staff and resident files are always confidential. LPA Gonzalez toured the reception area and observed that resident files were located in the reception office and the staff files in a room inside the reception office. Staff Bustillos opened the door where the staff files are located. Based on LPA tour and observations and interviews conducted with facility staff there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Staff failed to treat resident's with dignity and respect, it is alleged that residents are regularly mistreated. Interview with Administrator Noemi Biely revealed that residents are never mistreated and are always treated with dignity and respect. Interviews conducted with facility staff reveal that all residents are treated with dignity and respect and are never mistreated by anyone. Interviews with R1-7 revealed that they are treated with respect and that facility staff are patient and properly tend to their needs. LPA toured the facility and observed staff tending to residents throughout the facility and it appeared that their interactions with residents were respectful. Based on LPA observations, interviews conducted with facility staff and residents there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Administrator Noemi Biely.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2020

LIC9099 (FAS) - (06/04)

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