Fairwinds - Woodward Park

Type of visit: Case Management - Other

On 8/4/2023 at 10:40 a.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a case management for a death report previously submitted to the department. LPA entered the facility and was greeted by staff. LPA met with Administrator Desiree Valero and explained the reason for the visit. Administrator went over the events that took place when R1 fell on 6/14/23. S1 was one of the staff members who assisted R1 when they fell. LPA interviewed S1. On 6/14/23 R1 fell in the hall way of the facility and S1 assisted with the call. S1 called for backup and 2 staff members assisted R1 to their feet with a walker. S1 walked with R1 to their apartment. S1 tended to R1's wound on the arm. S1 also called and informed family members of the incident. Thirty minutes after S1 left R1's apartment paramedics arrived to the facility to take R1 to the hospital. LPA did not find any deficiencies and no citations were issued at this time. Exit interview was conducted and a copy of this report (LIC809) was provided to Administrator Desiree Valero.the state’s words, verbatim · CDSS document, Aug 4, 2023

Allegation investigated: Staff did not ensure HVAC was working properly

On 5/18/23 at 5:15 p.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an investigation for the allegation listed above. LPA introduced herself and met with Administrator (AD) Desiree Valero, LPA explained the reason for the visit. AD stated each apartment has its own individual AC unit. While talking with AD it was discovered there were 4 A/C units needing repair within the past week. AD stated three of the four units needing to be repaired were repaired from an outside company. One AC unit was repaired by facility. Invoices for A/C units needing repairs was collected from the facility. See LIC9099C for continued report. Substantiated LPA interviewed various residents through out the facility. It was stated to LPA facility took from 7 days to 3 weeks to fix AC units. As LPA toured the facility and went to all three floors, LPA observed thermostats to not be in working order. Example one thermostat in the hallway of the third floor East Wing was set to 80 degrees F and the temperature read 86 degrees F. In another hallway first floor East Wing was set to 74 degrees F and read 81 degrees F. LPA observed the stairwell door from the third floor open with the window open. Current outside temperature is showing at 91 degrees F 1. The Department investigated the allegation: Staff did not ensure HVAC was working properly. LPA toured the facility and observed facility to not be at a comfortable temperature. LPA observed thermostats at the facility to read at 79 degrees or above when thermostats were set to a lower temperature. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Exit interviewed conducted with AD, copies of LIC9099, LIC9099C, and LIC9099D were provided.the state’s words, verbatim · CDSS document, May 18, 2023 · control 24-AS-20230518094106

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b)(2) · Plan of correction due date: May 19, 2023

87303(b)(2) Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement is not met as evidenced by: Based on LPAs observations, interview, and record reviews, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed various thermostats which did not show AC to be working properly. LPA conducted various interviews which stated facility took 7 days or longer to repair AC units in apartments.the state’s words, verbatim · CDSS document, May 18, 2023

Plan of correction: Administrator sent an email to have work order created tomorrow. Administrator stated will get AC units & fans throughout hallways. Administrator will send pictures of AC units and fans throughout the hallways of the facility.

Type of visit: Required - 1 Year

On 3/24/2023 at 11:20 a.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility to conducted an unannounced Annual Required Inspection. LPA toured the facility with Administrator/General Manager Desiree Valero. LPA explained the reason for the visit and a tour was conducted. LPA toured the facility inside and out. LPA observed exits to be clear and free from obstructions. LPA observed fire extinguishers to be current and in good standing. Water temperature was taken in 2 common area bathrooms and one vacant room. The common areas, beauty shop, activities room and dining room were all toured. LPA observed adequate seating and lighting for resident throughout facility. LPA observed residents participating in different activities throughout facility tour. The kitchen was toured. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. All food was labeled and properly stored. LPA observed kitchen staff wearing gloves and masks. LPA observed facility to be clean and free from clutter. LPA also observed various residents interacting with one another and with staff. Resident files reviewed. Staff files reviewed. Medications observed to be locked in medication room and inaccessible to residents. Exit interview was conducted and a copy of this report & LIC809C was provided to AD. RCFE Docs Residential Care Facility for the Elderly (RCFE):  LIC 308 Designation of Facility Responsibility  -as applicable: LIC 309 Administrative Organization  -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources  -as applicable: LIC 402 Surety Bond  LIC 500 Personnel Report  LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly  LIC 9020 Register of Facility Clients/Residents  Copy of current Liability Insurance  Copy of current Administrator Certificate  Alternate contact information including name, telephone number, & email address. Requested information will be due by 4/7/2023the state’s words, verbatim · CDSS document, Mar 24, 2023

Allegation investigated: Staff mishandled a resident's medication while in care resulting in resident's hospitalization.

On 10/17/22 at 11:15 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to deliver the findings. LPA explained the reason for inspection and met with Administrator Desiree Valero. LPA reviewed records and conducted interviews. Based on review of records, the allegation that staff mishandled a resident's medication resulted in the resident's hospitalization is unsubstantiated. Review of records show that upon admission to the hospital, R1's vitals were stable. No documentation was observed to indicate that R1's admission to the hospital or eventual diagnosis was related to medication mishandling. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted. A copy of this report was given to Administrator Desiree Valero, whose signature confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 17, 2022 · control 24-AS-20220613105348

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 10/17/22 at 3:00 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - deficiencies inspection. LPA explained the reason for inspection and met with Administrator Desiree Valero. LPA found that on 6/5/22, R1's medication Ciprofloxacin 500 mg Tabs (Take 1 tablet orally two times daily) were given three times at the times of 8:10 AM, 5:37 PM, and 7:22 PM. On 6/7/22, the facility received new Amlodipine 5mg (Take 1 tablet orally daily) from the pharmacy some time in the evening of the day and S1 administered a dose the same evening after finding that the new medication was received and in the med room. The facility had already given the medication Amlodipine 10mg (Take 1 tablet orally daily) earlier that day at 6:30 AM. LPA found that the facility did not receive the doctor's order for the change in dosage for the medication until 6/8/22. LPA found that R1's medication bubble pack Amlodipine 10mg that was filled on 4/21/22 to be started 5/1/22 and the bubble pack Amlodipine 10 mg that was filled on 5/20/22 to be started 5/29/22 was recorded on the Centrally Stored Medication sheet and in the facility's internal digital medication administration log as given, but both bubble packs were still intact and full without any doses administered. CCL received a faxed incident report on 6/20/22 for an incident that occurred on 6/10/22. The facility sent an incident report to CCL on 6/23/22 for an incident that occurred on 6/7/22. Deficiencies are being cited based on LPA's observations, interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A civil penalty of $250 is being assessed for a repeat violation of CCR 87211(a)(1)(D) which was first issued on 6/2/22. See LIC421FC for more details. Exit interview conducted and Plan of Corrections were developed and reviewed with Administrator Desiree Valero. A copy of this report and appeal rights were given to Administrator, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Oct 17, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 31, 2022

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: LPA found that on 6/5/22, R1's medication Ciprofloxacin 500 mg Tabs (Take 1 tablet orally two times daily) were given three times at the times of 8:10 AM, 5:37 PM, and 7:22 PM. On 6/7/22, the facility received new Amlodipine 5mg (Take 1 tablet orally daily) from the pharmacy some time in the evening of the day and S1 administered a dose the same evening after finding that the new medication was received and in the med room. The facility had already given the medication Amlodipine 10mg (Take 1 tablet orally daily) earlier that day at 6:30 AM. LPA found that the facility did not receive the doctor's order for the change in dosage for the medication until 6/8/22. LPA found that R1's medication bubble pack Amlodipine 10mg that was filled on 4/21/22 to be started 5/1/22 and the bubble pack Amlodipine 10 mg that was filled on 5/20/22 to be started 5/29/22 was recorded on the Centrally Stored Medication sheet and in the facility's internal digital medication administration log as given, but both bubble packs were still intact and full without any doses administered. Which poses a potential health and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 17, 2022

Plan of correction: Administrator will submit proof of in-service training roster with an agenda to CCL by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Oct 31, 2022

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D)...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: CCL received a faxed incident report on 6/20/22 for an incident that occurred on 6/10/22 and the facility sent an incident report to CCL on 6/23/22 for an incident that occurred on 6/7/22, which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2022

Plan of correction: Administrator will submit proof of a written statement about the facility's plan to ensure timely submission of incident reports to CCL by POC due date.

Type of visit: Case Management - Other

On 8/2/22 at 3:07 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other inspection. LPA checked in at reception desk. LPA met with Administrator (ADM) Desiree Valero and explained reason for inspection. LPA toured the facility kitchen with ADM and observed approximately 4-6 ceiling panels removed, exposing HVAC system. LPA observed refrigerator and freezer in working order. LPA observed kitchen thermostat set at 76 degrees F and was measuring at 81 degrees F. Kitchen thermostat was located on wall close to doors leading out to dining area. LPA interviewed staff and reviewed records. LPA found that the main AC unit in the kitchen is currently turned off to prevent the AC water pipe leak that recently occurred. Facility is waiting for HVAC company to schedule the appointment for service on the AC water pipe leak to be able to turn water back on for the AC. Deficiency is being cited based on LPA's observations, interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. Exit interview conducted. A copy of this report and appeal rights were given to Administrator Desiree Valero, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Aug 2, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 9, 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 is not met as evidenced by: LPA found that the main AC unit in the kitchen is currently turned off to prevent the AC water pipe leak that recently occurred. Facility is waiting for HVAC company to schedule the appointment for service on the AC water pipe leak to be able to turn water back on for the AC, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 2, 2022

Plan of correction: Administrator will submit proof of appointment made for service to be conducted for repair of the AC water pipe leak to be conducted within the next week to CCL by POC due date.

Allegation investigated: Staff did not issue a refund to resident.

On 6/22/22 at 9:16 AM Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint inspection. LPA checked in at front desk and met with Administrator (ADM) Desiree Valero. LPA explained reason for inspection. LPA reviewed records and conducted interviews. Based on records review and interviews, LPA found that the facility issued the refund to R1 within 30 days as agreed upon in the admission agreement of page 5, item number 17. This agency has investigated the complaint alleging staff did not issue a refund to resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted. A copy of this report was given to Administrator Desiree Valero, whose signature confirms receipt of this report. Unfoundedthe state’s words, verbatim · CDSS document, Jun 22, 2022 · control 24-AS-20220614100748

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility failed to issue the full refund amount.

On 6/22/22 at 9:16 AM Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint inspection. LPA checked in at front desk and met with Administrator (ADM) Desiree Valero. LPA explained reason for inspection. LPA reviewed records and conducted interviews. LPA found that the facility issued a prorated refund to R1 for the dates of 5/27/22 through 5/31/22. R1 issued a written 30-day notice to vacate dated 4/24/22 to the facility front desk on 4/26/22. Facility noted the date of 4/27/22 as date notice was given by R1. Facility could not locate the written notice and did not record date of actual receipt of written notice by R1. S1 admitted the date of 4/27/22 is noted from another staff's verbal notice and did not receive or review the original written notice by R1. Therefore, the above allegation is unsubstantiated. Exit interview conducted. A copy of this report was given to Administrator Desiree Valero, whose signature confirms receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 22, 2022 · control 24-AS-20220614100748

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: POC

On 6/22/22 at 8:34 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a POC visit. LPA checked in at front desk and met with Administrator (ADM) Desiree Valero. LPA explained reason for inspection. Deficiency was issued on 6/2/22 for violation of CCR 87211(a)(1)(D). Plan of correction was due on 6/16/22. As of today, 6/22/22, CCL has not received the Plan of correction as created and agreed upon on 6/2/22. Administrator admits the Plan of correction had not been completed or submitted to CCL. Civil penalties are being assessed for failure to correct CCR 87211(a)(1)(D) for the period of 6/17/22 through 6/22/22 (6 days) in the amount of $100 per day per citation, for a total of $600. A civil penalty of $100 per day per citation will continue until deficiency is corrected. See form LIC421FC for more detail. Exit interview was conducted. A copy of this report and appeal rights were given to Administrator Desiree Valero, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Jun 22, 2022

Type of visit: Case Management - Other

On 6/2/22 at 8:35 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other inspection. LPA explained reason for inspection and met with Administrator (ADM) Desiree Valero. On 5/20/22, CCL received three Special Incident Reports (SIRs) from the ADM reporting a total of 11 residents and 1 staff that tested positive for COVID-19. Of the total 12 reported positive persons, 1 resident tested positive on 4/29/22, 1 staff tested positive on 5/6/22, 1 resident tested positive on 5/10/22, 1 resident tested positive on 5/12/22, 1 resident tested positive on 5/15/22, 4 residents tested positive on 5/16/22, and 3 residents tested positive on 5/17/22. On 5/21/22, CCL received a SIR from the ADM reporting 2 residents and 1 staff that tested positive for COVID-19. All 3 identified positive persons were tested on 5/17/22. LPA received a voicemail from S1 on 5/4/22 reporting the facility identified 2 positive persons. LPA returned S1's call the same day and left a voicemail advising the facility must submit a SIR to CCL as soon as possible. LPA did not receive the SIR for the identified positive persons reported on 5/4/22 by S1 until 5/20/22. Deficiency is being cited based on LPA's record review in accordance with the California Code of Regulations, Title 22, see LIC809D. Exit interview conducted. A copy of this report and appeal rights were given to Administrator Desiree Valero, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Jun 2, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 16, 2022

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D)...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: CCL received a SIR on 5/20/22 reporting 12 positive persons. Of the total 12 reported positive persons, 1 resident tested positive on 4/29/22, 1 staff tested positive on 5/6/22, 1 resident tested positive on 5/10/22, and 1 resident tested positive on 5/12/22, which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: Administrator will submit proof of in-service training roster for training topic of Reporting Requirements to all staff designated to assist Licensee in reporting incidents to CCL by POC due date. LPA provided a printed copy of CCR 87211 Reporting Requirements to Administrator during inspection.

Type of visit: Case Management - Other

On 4/1/22 at 9:20 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other inspection. LPA was greeted by the front desk and explained reason for inspection. LPA met with Health Wellness Director Pauline Barker. Administrator Desiree Valero was unavailable for the inspection, but was available via telephone. LPA obtained records for R1. No deficiencies cited during this inspection. Exit interview conducted. Due to COVID-19 precautions, a copy of this report will be emailed to Administrator with Read receipt to confirm receipt of this report.the state’s words, verbatim · CDSS document, Apr 1, 2022

Type of visit: Required - 1 Year

On 3/25/22, Licensing Program Analyst, M. Medina arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA observed a central entry point with a supply of hand sanitizer located upon entry. A sign in policy that includes documented routine symptom screening for visitors is currently being implemented to follow current visitation guidelines. All staff are screened upon arrival for shift. Mitigation plan was received and approved by Department on 2/23/2021. LPA toured the facility inside and out. Staff were all observed wearing face coverings. Facility has designated visitation areas. LPAs observed a 30 day supply of PPE and resident medications. Several residents rooms in Assisted Living apartments toured and observed to have adequate soap and paper products available. Administrator to submit LIC 500, LIC 610E and resident roster to Fresno CCL office no later than 4/1/2022. Through LPA's observation of documentation and interview with Administrator, the required infection control practices are found to be in compliance. No deficiencies were observed. Exit interview was conducted and report signed. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed.the state’s words, verbatim · CDSS document, Mar 25, 2022

Allegation investigated: Facility is overcharging resident.

On 11/15/21 at 8:25 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint inspection. LPA met with Operations Manager Jessica Sommer and Assistant Manager Desiree Valero. During the course of the investigation, LPA conducted interviews, and reviewed records. Based on interviews, and record review, LPA found that the facility overcharged the resident $9408. R1 was charged for services that R1 did not agree to receiving and the facility could not produce documents to show R1 agreed to services. The above allegation is substantiated. Deficiency is being cited based on LPA interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC9099D. Exit interview conducted. A copy of this report will be emailed to Assistant Manager Desiree Valero with "Read receipt" to confirm receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Nov 15, 2021 · control 24-AS-20210614082006

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.657 · Plan of correction due date: Nov 16, 2021

§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement is not met as evidenced by: Based on interviews and records review, LPA found that the facility overcharged the resident $9408. R1 was charged for services that R1 did not agree to receiving and the facility could not produce documents to show R1 agreed to services. This poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2021

Plan of correction: Operations Manager Jessica Sommer will reimburse R1 $9408 through crediting R1's rent account. Resident statement was provided as proof rent account was credited. POC cleared during inspection.

Allegation investigated: Facility is in disrepair.

On 7/15/21 at 10:30 am, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an initial 10-day complaint investigation. LPA met with Administrator (ADM) Deanne Edwards. During the course of the investigation, LPA conducted interviews and reviewed records. Based on observations, interviews, and records review, LPA found that all work orders placed for R1 were completed or pending completion. One work order has been pending 3 weeks, but is on order for a new replacement. The above allegation is unsubstantiated. Exit interview conducted. A copy of this report will be emailed to Administrator Deanne Edwards at dedwards@leisurecare.com. Email sent with read receipt to confirm receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 15, 2021 · control 24-AS-20210707083733