Maple Avenue Guest Home

Allegation investigated: Staff spoke to resident in an inappropriate manner Staff does not perform job duties

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to deliver the complaint investigation findings. LPA met with Administrator (AD) Camalah Kopacz and explained the purpose of the visit. 1. The Department investigated the allegation: Staff spoke to resident in an inappropriate manner. Multiple residents were interviewed. None of the residents who were interviewed stated that staff yell or speak inapparently. It was reported that some residents are resistive to assistance and staff may raise their voices to gain resident attention. 2. The Department investigated the allegation: Staff does not perform job duties. During an interview, the A described the staff job duties. Per AD, prior to admission individuals are assessed to determine that they are ambulatory and require minimal care. A record review was conducted. AD did not have a document which states the responsibilities and duties of the live-in staff members. See LIC9099-C for continuation of this report. Unsubstantiated Based on interviews conducted and record review, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore the allegation is unsubstantiated. No citations were issued for these allegations. An exit interview was conducted, and a copy of this report was left with Camalah Kopacz, whose signature on this form confirm receipt of these documentsthe state’s words, verbatim · CDSS document, Nov 7, 2022 · control 24-AS-20220715163911

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Katie Brown arrived at the the facility unannounced to conduct a Case Management related to observations of violations during a complaint investigation visit on 7/22/2022. LPA met with Camalah Kopacz and explained the purpose of the visit. During a facility visit on 7/22/2022, LPA Brown made the following observations: 1. Storage Space: Accessible cleaning products under the bathroom counter Multiple disposable razors placed on top of a paper towel dispenser in resident bathroom 2. Maintenance and Operation: A piece of cardboard covering a broken windowpane (kitchen window). Dirty resident bedroom floors, baseboards and windowsills, walls, light-switch covers, shower floors Pile of baskets and trash at the top of the stairs into staff room Broken bedroom furniture in resident rooms - Night stands and dressers missing drawers Broken hanging blinds 3. Personal Accommodations and Services: Multiple resident beds with soiled sheets and missing required bedding Multiple resident rooms smell of urine 4. Fire Safety: A dresser blocking an Emergency Exit in a resident room to keep a resident from leaving the facility See LIC809-C for continuation of this reportthe state’s words, verbatim · CDSS document, Nov 7, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(1) · Plan of correction due date: Nov 8, 2022

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement was not met as evidenced by: Licensee did not ensure that chemicals/cleaning supplies and items which could pose a danger to resident if readily available were locked and properly stored. LPA observed 3 disposable razors and unlocked cleaning supplies stored accessable being stored in resident bathroom. This poses an immediate health, safety or personal rights risk to reisdents in care.the state’s words, verbatim · CDSS document, Nov 7, 2022

Plan of correction: DEFICIENCY CLEARED. All disinfecting/cleaning products were observed to be locked and inaccessable to residents in care. Residents do not have access to razors or sharps which are locked.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Nov 21, 2022

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 was not met as evidenced by: Licensee did not ensure the facility is clean, safe, sanitary and in good repair. LPA observed a broken window pane, dirty bedroom floors, baseboards and windowsills, walls, broken bedroom furniture with missing drawers and broken blinds in resident rooms. This poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2022

Plan of correction: AD agrees to create a deep cleaning check list and schedule that reflects that each room is deep cleaned monthly. The schedule and checklist will be provided to CCLD by the due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Nov 21, 2022

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function….(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident…(C) Clean linen, including blankets, bedspreads, top bed sheets,bottom bed sheets, pillow cases, mattress pads…. to ensure that clean linen is in use by residents at all times…. This requirement was not met as evidenced by: LPA observed multiple residents beds with soiled or missing required linens. Multiple resident rooms smelled of urine. This poses a health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2022

Plan of correction: AD has agreed to provide a written statement that documents that the regulation has been reviewed and the requirements are understood. AD will include the facility daily and weekly linen change protocol. This statement will be submitted to CCLD by the due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87203 · Plan of correction due date: Nov 21, 2022

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Licensee did not maintain in conformity with the regulations adopted by the State Fire Marshal. LPA observed a dresser placed blocking an Emergency Exit door which staff stated was placed to keep resident from leaving through the door. This poses a health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2022

Plan of correction: DEFICIENCY CLEARED LPA observed that the emergency exit was free of obstruction upon entering the facility.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Inspection - Infection Control. Upon arrival, a staff member contacted Administrator (AD) Camalah Kopacz who arrived at the facility. LPA toured the facility inside and out. Upon entry, LPA observed visitor log/symptom screening and sanitizer. Covid-19 symptom and precautionary signs are posted at entry and throughout the facility. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed soap, paper towels and hand washing postings in bathrooms. LPA observed required food supply, paper products, available PPE and resident medications. Cleaning/disinfecting products were locked. LPA reviewed resident emergency contact information. Fire and Carbon Monoxide alarms were observed in working order. LPA observed fire extinguishers dated 5/29/22. AD has agreed to revise and re-implement the resident and staff daily symptom screening. No deficiencies were cited during this inspection. An exit interview was conducted. A copy of this report was left with Camalah Kopacz whose signature confirms receipt of these documents. LPA requested the following updated forms by 11/21/22: LIC 308, LIC 400, LIC 402, LIC 500, LIC 610E, LIC 9020, a copy of current Liability Coverage and Administrator Certificate.the state’s words, verbatim · CDSS document, Nov 7, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Annual Inspection visit. LPA Williams met with Administrator, Camalah Kopacz , and discussed the purpose of the visit. LPA Williams toured the facility. LPA Williams observed a visitor/temperature log, masks, and hand sanitizer station. Facility has one entry and exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas. LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked door and medication behind a locked cabinet. LPA Williams observed the following personal protective equipment in storage; gown, goggles, gloves, and masks. LPA Williams observed all facility staff wearing masks. Resident’s files have updated emergency contact information. No deficiencies were cited at this time. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 17, 2021

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.