The New Light Residential Care Home

Allegation investigated: Staff do not respond to residents call at night Staff are sleeping during their shift

On 10/6/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to deliver complaint findings. LPA met with Direct Care Staff, Bea Choua, explained reason for visit and was permitted entry into the facility. Administrator, Carlo Santos was contacted and arrived a short time later. A health and safety was completed for residents in care. During investigation LPA completed interviews with staff and resident(s) and reviewed documentation (physicians reports, needs and assessments). Records reviewed indicated that 4 of 6 residents have been diagnosed with dementia. Interviews conducted with staff indicated that 1 of 6 residents have wandering tendencies. Interviews with staff and resident(s) showed there are 2 live-in staff that work at the facility. Both staff are awake staff during the day and sleep during the nights. Resident(s) interviewed stated when they pushing the call light for assistance, staff do not always answer. R1 stated they have had to go to staffs room to "bang" on the door for assistance. The allegations above meet the preponderance of evidence standard per Title 22. The allegations are SUBSTANTIATED.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 24-AS-20230501092207

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4)(A) · Plan of correction due date: Oct 9, 2023

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement was not met as evidence by: interviews completed with staff and resident(s) support the allegation of staff sleeping during their shifts. This poses a immediate health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2023

Plan of correction: Administrator to provide POC in writing by POC date. Training will be given as needed to staff. In-service sign in sheet to be provided to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 13, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidence by LPA interviews with staff and residents. Call buttons are not being answered when residents are calling for assistance. This poses a potential health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2023

Plan of correction: Administrator will assess practices and test equipment 1x month and keep log. Changing batteries as needed. In service training will be completed with staff to institute best practices. In-service training sign in sheet will be provided to CCL by POC date.

Allegation investigated: Staff lock residents in their rooms

On 10/6/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to deliver complaint findings. LPA met with Direct Care Staff, Bea Choua, explained reason for visit and was permitted entry into the facility. Administrator, Carlo Santos was contacted and arrived a short time later. A health and safety was completed for residents in care. During investigation LPA completed interviews with staff and resident(s). Records reviewed indicated that 4 of 6 residents have been diagnosed with dementia and were unable to be interviewed. Interviews conducted with staff and resident(s) do not support the allegation. Although the allegation may or may not have occurred, the allegation above does not meet the preponderance of evidence standard per Title 22. The allegation is UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, Oct 6, 2023 · control 24-AS-20230501092207

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: Required - 1 Year

On 8/24/23 Licensing Program Analyst (LPA) M. Garza arrived for an unannounced annual inspection visit. LPA was met by Direct Care Staff, Joseph and Bae Chua. Administrator, Carlo Santos was contacted and arrived some time later. LPA introduced self, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. Residents observed in common area and in rooms. LPA toured the facility inside and out. There was 3 residents on hospice at the time of inspection. Pathways and doors inside facility were clear and free from obstruction. Inside facility was without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors present and operational at time of visit. Fire extinguisher last serviced 9/20/22. Last fire drill on 5/23/23. Water temperature measured 96.2 degrees F in kitchen and 112 degrees F in bathroom #2. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps kept in a locked cabinet under the kitchen sink, medications kept locked inside a locked cabinet. CONT... CONT... The following issues were observed during the visit: trash cans observed with lids but not closed. Trash can in living room area does not have a lid. Blinds on back room windows observed to be dirty and in disrepair. Side gate does not self latch. Gate tied closed with a metal wire. Patio observed with debris, chemicals and tools. Storage room off patio opened and cluttered. Facility in need of general house keeping for the outside of the facility (clutter/spider webs). Water heater observed to be leaking. Water hose in walkway off patio. Fence boards missing on back fence. Debris behind garage. Garage unlocked and observed with clutter/debris. Chemicals in hallway closet near laundry unlocked. Laundry room unlocked with chemicals accessible. Food in pantry not properly stored. Wood rot under kitchen sink. Restroom door left ajar by staff while in use by resident. Restroom #1 observed dirty around toilet flooring. Oxygen signs not posted on resident doors. 1 of 6 resident rooms observed without bulb in lamp. Water temperature in kitchen measured at 96.2 degree F. LPA requested the following documents to be submitted to CCL by 8/31/23: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. Due to time constraints, LPA will return at a later date for an annual continuation and to cite deficiencies. Exit interview completed with Administrator, Carlo Santos. A copy of this report.the state’s words, verbatim · CDSS document, Aug 24, 2023

Type of visit: Required - 1 Year

On 6/24/22, Licensing Program Analyst (LPA) M. Medina conducted an Annual Required Infection Control Inspection. LPA Medina introduced self and allowed entrance by met by Direct Care Staff. Administrator, Carlo Santos contacted by telephone and arrived a short time later to conduct facility inspection. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point through front door. All residents were present during facility inspection. Tour of the facility conducted with Administrator. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Resident bedrooms toured, all resident bedrooms are private and have adequate lighting and furnishings. LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available. Fire extinguisher present with a service date of 7/17/2021. LPA observed carbon monoxide and smoke detectors present and operational during today's inspection. Water temperature measured at 107 degrees F. Licensee to submit Administrator Certificate, first Aid, LIC 500, LIC 610 and LIC 9020 to Fresno CCL office no later than 7/05/22. No deficiencies were observed. Exit interview was conducted. A copy of this report provided for facility records.the state’s words, verbatim · CDSS document, Jun 24, 2022