Regarding the allegation that, Facility did not have sufficient staffing to meet the needs of the resident(s) in care, the following has been concluded: Based on the LIC500 Personnel Report form dated July 20, 2022. The facility only has two caregivers on staff with no provisions for weekends, nights and potential absences and sick days. At the time, there were two residents admitted to the facility per the Register of Facility Residents (LIC9020), both of which are non-ambulatory and receive hospice care, therefore the lack of planned contingencies is a risk for the health and safety of both residents in care. Bridge hospice visits notes dated January 14, 2022, indicate: “[Skilled Nurse] provide a detailed education to staff on keeping the wound clean. Staff at [board and care] are overwhelmed. SN attempted to educate related to the patient’s condition. Staff told SN we are not medical professionals. Staff in the home appear overwhelmed and anxious. SN reported to nursing supervisor and to the patient’s [R1] son.”

Regarding the allegation that, Facility did not maintain required liability insurance, the following has been concluded: The Department requested proof of required liability insurance to the license and reviewed the documentation provided. The coverage reviewed was found to not meet the requirements of Health and Safety Code Section 1569.605 stating coverage should “have a least one million dollars per occurrence and three million dollars in the total annual aggregate”. The licensee’s policy provided such coverage for two separate LLC entities and up to three facilities over some periods. It was also found that coverage had lapsed for the period from January 17, 2022, until February 14, 2022, indicating that the licensee did not have liability coverage for that period.

Regarding the allegation that, Facility funds are not sufficient to meet operating needs, the following has been concluded: After reviewing the available documentation, the Department determined that the licensee does not have an adequate financial plan to ensure residents’ care and supervision won’t be interrupted. CONTINUED ON LIC9099-C

Regarding the allegation that, Facility failed to obtain a physician report prior to being admitted, the following has been concluded: The physician report for R1 is neither dated nor signed and therefore does not meet the requirements established in Title 22 regulations applicable to resident records. There is additionally no indication of R1’s tuberculosis status. Given the absence of a valid physician report in R1’s records, the allegation is Substantiated.

Regarding the allegation that, Facility did not adequately assess resident prior to admission, the following has been concluded: The physician report on file does not indicate whether R1 has any indications of tuberculosis or other transmittable diseases prior to admission. The assessment conducted prior to admission within the facility does therefore not meet Title 22 requirements. The allegation is found to be Substantiated.

Regarding the allegation that, Staff were not adequately trained, the following has been concluded: email staff records provided to LPA Reed in July 2022 by facility administrator failed to evidence that both staff members scheduled at the facility during R1’s admission had received any and/or sufficient initial and recurring annual training beyond some training evidenced to have been received in 2019 prior to either staff members being hired in October 2021 by the facility.

Regarding the allegation that, Staff did not document resident's change in condition, the following has been concluded: Following an initial request and multiple follow-ups for licensing staff, facility staff provided the Department with resident records for R1. No charting notes are present. While recurring hospice visits are adequately documented from admission on December 3, 2021, until the resident’s passing on January 15, 2022, there appears to be no documentation of facility staff interventions. Upon the resident’s change of condition when R1 appears to start actively transitioning per hospice staff, no reassessment of the resident’s condition or ambulatory status were documented or presented as evidenced during the investigation.

Regarding the allegation that, Facility failed to provide a request for records from Attorney, the following has been concluded: The law office representing the responsible party for resident R1 made a formal request for records from the facility staff on April 18, 2022 and had not received applicable documentation at the time of the present complaint being filed in July 2022. CONTINUED ON LIC9099-C

Regarding the allegation that, Facility violated fire clearance by retaining a bedridden individual, the following has been concluded: Based on the documentation on file provided by facility staff, the resident appraisal for R1 is not fully consistent and states that R1 is bed-bound and spends most of the time in bed. The physician report provided does not indicate on the other hand that the resident was either bedridden or unable to reposition in bed independently. One care staff interviewed during the initial investigation visit stated R1 could not reposition themselves independently. Other staff interviewed were not questioned on the matter. Hospice plan of care review conducted by Vitas Hospice staff on December 9, 2021, lists the residents as bedbound. The Hospice assessment established by Bridge Hospice on January 13, 2022, also indicates the resident is bedbound. Additionally, the content of the physician report cannot be fully corroborated due to the absence of indication of the identity of the physician responsible for the assessment along with the fact that the document is neither signed nor dated. As a result, the allegation is Substantiated.

Regarding the allegation that, Facility did not report incident(s) which threatened the welfare, safety or health of any resident in care, the following has been concluded: Per a review of hospice records provided by Vitas Hospice, hospice staff was called to follow-up on a fall incident during which R1 was found face up on the floor at approximately 6:00am on December 13, 2021. Full assessment was conducted and found no injuries, fall mats were ordered. A review of the incident reports submitted to the Orange County Regional Office found no evidence of an incident report being filed following the fall occurrence.

As a result of the investigation, the ten allegations listed above are found to be Substantiated, meaning that the preponderance of the evidence standard has been met. Ten citations are issued and documented on attached forms LIC9099-D.

An exit interview was conducted, and a copy of this report and appeal information was provided to a facility Administrator Tin Le during the visit.

Regarding the allegation that Facility funds are commingled, the following has been concluded: Based on the audit and review of the facility’s funds and finances, funds for two distinct licensed locations “were mixed and transfers between the accounts took place when needed. It’s unclear if funds shifted from Fountain Gardens to cover Cyecrest Home and caused a negative impact on Fountain Gardens’ financial stability”. The audit also demonstrated that according to bank statements reviewed, “the licensee is mixing personal and business expenses”. However, there was no evidence of misappropriation of resident’s funds during the solvency audit conducted.

Regarding the allegation that Staff did not administer medication(s) to resident according to their physician's instructions and that Staff did not follow physician's orders for resident in care, the following has been concluded: Paper Medication Administration Records for the period of December 3^rd, 2021 until January 1, 2022 have been provided by facility staff and appear to document correct administration in accordance with the physician orders made at the time. Hospice records established by Bridge Hospice for the remainder of January 2022 until R1’s passing also appear to demonstrate adequate medication administration. However, no further verification could be completed after R1’s passing, therefore there is insufficient evidence to either dismiss or corroborate the allegation.

Regarding the allegation that Facility Administrator failed to meet administrator requirements, the following has been concluded: Based on a review of the facility’s compliance history in addition to records provided, it has been evidenced that the designated administrator was certified to have completed the Residential Care of the Elderly Administrator Certification Program effective July 26, 2021 and valid until July 25, 2023. Current administrator status verified. CONTINUED ON LIC9099-C

Regarding the allegation that Staff did not meet resident's hygiene & toileting needs, the following has been concluded: Based on the assessments conducted upon admission, R1 was diagnosed with bowel incontinence. Hospice staff is documenting that proper perineal care was reviewed with facility staff on December 8, 2021, in addition to hospice care providing resident with a sponge bath. Use of adult diapers documented. Sponge bath and perineal care were also documented on December 13, 15, 17, 20, 22, 24, 27, 29 as well as January 3, 5, 7, 10, 2022.

Regarding the allegation that Facility retained a resident who needed a higher level of care, the following has been concluded: Based on the physician report established upon R1’s transfer from Citrus Hills Assisted Living to the present licensed facility, the resident was not assessed to require continuous nursing care which would have been incompatible with R1’s placement in a RCFE. An additional assessment by the Vitas Hospice RN on December 8, 2021, documented that the placement at the board-and-care was sufficient to address R1’s needs in place. On multiple occasions, hospice staff certified an absence of environmental or safety concerns at the facility.

Regarding the allegation that Staff did not meet resident's hydration needs, the following has been concluded: Based on a review of hospice records provided by both hospice providers involved in caring for R1 between December 2020 and January 2022, it was evidenced that R1 was diagnosed with “dysphagia following cerebral infarction” as early as December 17, 2020 and first placed under hospice care at that time, with additional documented lack of appetite. Hospice records indicate a fixation upon water and repeated requests for water verbalized by R1 in the days leading to their passing, however no indication is made of a failure from staff to meet hydration needs. Admission report dated January 13, 2022, for Bridge Hospice states “Patient is eating and drinking well per facility staff. (…) Agitation: focused on her son and water. Needs prompt to remain cooperative and calm during the assessment. (…) Intake: 80% of regular size meal.

Regarding the allegation that Staff did not notify resident's representative about resident's change in condition, the following has been concluded: CONTINUED ON LIC9099-C

Based on the evidence gathered during the investigation, the nine allegations listed above are found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted, and a copy of this report was provided to Administrator Tin Le during the visit.

Regarding the allegation that Resident developed Stage 4 pressure injuries while in care due to neglect, the following has been concluded: Based on a review of resident R1 physician report maintained at the facility, there was a history of skin breakdown assessed upon admission. Due to the absence of name, date and signature on R1’s medical assessment, it cannot be fully relied on to corroborate whether any pressure injuries were present upon admission. However, hospice records provided during the investigation indicate that R1 was admitted on December 3, 2021, with an active hospice admission from December 2, 2021, already indicating the presence of a pressure sore on R1’s coccyx prior to the resident’s move-in at the facility. Hospice plan of care reviewed additionally included bi-weekly wound care, frequent repositioning and a low air loss mattress prior to their initial admission at the facility. Wound care and dressing changes are also regularly documented in the hospice records reviewed.

Based on that evidence, the presence and/or appearance of pressure injuries can therefore not be attributed to staff neglect or lack of care provided. The allegation is therefore found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided to Administrator Tin Le during the visit.