It was also alleged that the responsible party for R1 was having trouble with the facility’s billing policies, in particular those relating to the “regular” fees charged and increasing those fees more than once a year. The complaint also alleged that the facility did not inform R1’s responsible party of the change in R1’s level of care. During the investigation, LPA reviewed R1’s Admissions Agreement as well as R1’s Resident Assessments and resident ledger. Resident assessments were completed as follows: initial assessment Report Continued on LIC 9099-C

Pursuant to Title 22 CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.

The complaint alleges that in April 2021 at some point that the power went out at the facility and during the time the power was out that the door alarms did not function and residents were able to wander freely in and out of the building. Interview revealed that the facility does have a backup power generator in case of an extended loss of power. The outage in April reportedly lasted a few hours. Interview revealed that residents in the Memory Care unit are allowed to wander freely both indoors and outdoors as they please, per regulation. Staff either go out on the patio with the residents when they wander outside the building, or they watch the residents through the large glass windows in the dining room. Staff are aware of which residents wander and are more diligent in providing supervision to these residents. During the event of a power outage, the facility can use the generator to ensure refrigerated foods and medications remain at a safe temperature, Oxygen can be administered, and emergency lighting is provided. If the power is out for an extended period of time, the facility has access to a larger generator to run indefinitely. However, during the power outage in April, the large generator was not needed, as power was only out for a minimal amount of time. In the event of an emergency, interviews and emergency plan both indicate staff will monitor the exits to ensure no resident leaves the community. During the power outage, the concierge staff remained at the front desk to ensure residents did not leave through the front door and caregiving staff walked the hallways to ensure residents remained safe and inside the parameters of the facility indoor/outdoor space. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “facility did not provide a safe environment for residents in care” is deemed UNSUBSTANTIATED at this time.

Allegation: “Facility staff abandoned resident:”

The complaint alleges that on 01/04/2021 that R1 was hospitalized, during which time R1 tested positive for COVID-19. Interview with the complainant revealed that after a few hours, the hospital had cleared R1 to return to the facility, however, the facility did not readmit R1 and instead R1 remained hospitalized for 3

Report Continued on LIC 9099-C

Allegation: “Facility staff do not provide accurate records to resident’s responsible party:”

The complaint alleges that after R1 fell, R1’s responsible party requested to view care notes, video surveillance, and staff notes. The responsible party reports that they were told many conflicting stories about what documents could and could not be provided to the responsible party. Interview revealed that facility policies and HIPPA law dictate which documents can and cannot be provided to the families. Video surveillance is considered confidential, as other residents have a right to privacy and therefore cannot be provided to R1’s responsible party. Interview revealed that facility staff can provide basic documents, however the documents in question are protected by HIPPA. All care notes and notes related to a resident’s medical history are protected information. The resident’s responsible party would be allowed access to any and all assessments the facility has completed, including fall risk, care needs, and elopement risk, which are all based on the care notes and the care being provided to each resident. Facility staff did indicate that R1’s responsible party was provided with R1’s binder so that they could view all documents contained therein. However, interview revealed that R1’s responsible party was requesting copies of documents that the facility cannot provide. Based on interview and record review, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “facility staff do not provide accurate records to resident’s responsible party” is deemed UNSUBSTANTIATED at this time.

Report Continued on LIC 9099-C

The complaint alleges that the facility did not have a Family Council and that several resident/family members have been wanting to form a council. Interview with facility staff revealed that at the time of the allegation, there was a functional Resident Council at the facility. At different times, the Activity Director or the Business Office Director have served as the staff liaison for the resident council. But the resident council has been functional since 2020. When the facility experienced a COVID outbreak and Ventura County Public Health required closing all congregate activities, the council was not allowed to meet. However, apart from closing at the direction of public health, the resident council has been meeting regularly. As far as holding a family council specific to Memory Care, the facility did try to plan a family council around the time of the complaint allegation, but only had one or 2 families interested. At this time, the facility still plans to offer a family council specific to memory care if there is interest, including an educational aspect monthly. Admission Agreement for R1 reviewed did include a section that indicates “the resident’s family or representative have a right to form a Family Council.” Regulation indicates that “the facility shall permit the formation of a Resident Council by interested residents” as well as “a residential care facility for the elderly shall not prohibit the formation of a family council.” Interviews revealed that the facility has offered space to hold a family council meeting, but that there has yet to be a mutually agreed upon time and date for the meeting. Based on interview and record review, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “residents are not being allowed to form a resident council” is deemed UNSUBSTANTIATED at this time.

No citations issued in relation to the allegations listed above. Exit interview conducted. A copy of the report was provided during today’s visit.