Aspen Residential Care Homes Inc. II

Allegation investigated: Staff do not ensure privacy while providing personal care Staff do not ensure sanitary conditions when assisting resident with personal care Staff speak inappropriately to residents Staff are not assisting resident with shower as scheduled

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver the investigation findings to the facility. LPA met with and explained the purpose of the visit with Administrator (AD) Shelly Yarbrough. Staff members interviewed state that R1 is assisted with catheter care in the facility restroom or R1’s bedroom to ensure privacy. Record review of R1’s Restricted Condition Health Care Plan reveals that staff have been trained to ensure privacy during catheter care. Staff interviews were conducted and reveal that staff have been trained how to assist R1 with catheter care in a safe and sanitary manner. Record review of R1’s Restricted Condition Health Care Plan reveals that staff have been trained to ensure sanitary conditions during catheter care. See LIC9099C for continuation of this report. Unsubstantiated Staff members interviewed state that R2 has extreme emotional outbursts and can display “obsessive” behaviors desiring all of staff’s attention. Interviews reveal that staff have been trained with techniques about how to de-escalate and redirect R5. Record review reveals that these behaviors are noted in R2’s IPP. Staff members were interviewed and state that R3 received assistance with showers daily. Resident showers are documented on the facility Daily Care Collections Sheet. Record review was conducted of R3’s sheet for January 2023. Based on interviews and record reviews, 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. There were no citations issued An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 8, 2023 · control 24-AS-20230131110155

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff are working without criminal background clearance

Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct the initial 10-Day complaint visit. LPA met and explained the elements of the allegations with Administrator (AD) Shelly Yarbrough. During the visit, LPA conducted record review and interviewed AD. Based on record review and interview, LPA confirmed that Staff (S1) worked at the facility without Criminal Background Clearance. On 1/30/23 S1 was removed from the facility by AD. During the visit, LPA observed S2 was present at the facility without proper clearance. S2 was removed from the facility and cannot return to the facility until a fingerprint clearance is obtained. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. A Civil penalty in the amount of $500 is being assessed. See 9099C for continuation of this report Substantiated An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Shelly Yarbrough, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Feb 3, 2023 · control 24-AS-20230131110155

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Feb 3, 2023

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by: Licensee did not ensure that S1 and S2 obtained a Criminal Background Clearance prior to working at the facility. This poses an immediate Health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2023

Plan of correction: S1 was removed from the facility on 1/30/23. S2 was removed from the facility 2/3/23. S1 and S2 will not return to the facility until proper clearance is obtained. Defociency cleared during this visit.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Inspection - Infection Control. LPA met with and explained the reason for the visit with facility designee Karen Escobedo. LPA toured the facility inside and out. Upon entry, LPA observed a posted visitor policy, visitor log/symptom screening, sanitizer and PPE. Covid-19 symptom and precautionary signs are posted throughout the facility. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed soap and paper towels at all sinks, required food supply, paper products, 30-day PPE and resident medications. Cleaning/disinfecting products were locked. LPA reviewed quarantine/isolation procedures and staff vaccination requirements with AD. LPA observed the facility pool with required locked gate. LPA reviewed resident emergency contact information. Fire and Carbon Monoxide alarms were observed. Fire Extinguishers dated 11/15/2022. Administrator Certificate expiration 10/12/23. No deficiencies cited during this inspection. An exit interview was conducted. A copy of this report was left with Karen Escobedo whose signature confirms receipt of these documents. LPA requested the following updated forms by 10/7/22: LIC 308, LIC 309, LIC 400, LIC 402, LIC 500, LIC 610E, LIC 9020 and a copy of current Liability Coverage.the state’s words, verbatim · CDSS document, Sep 27, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a Case Management visit. LPA met with Administrator Shelly Yarborough and explained the purpose of the visit. The purpose of the visit is to obtain additional information regarding a Death Report that was received 11/2/21. The facility also self reported R1's death via telephone call to LPA on 11/2/21. During todays visit, LPA interviewed Administrator and staff (S1). LPA obtained records from Resident's (R1) file. Administrator agrees to submit the following to LPA by 5PM today: Hospital report (from PCP), S1's internal/facility Incident Report, R1's vitals log dates 10/29 - 10/31/21 and R1's list of medications. There are no deficiencies cited during this visitthe state’s words, verbatim · CDSS document, Nov 3, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with Administrator Shelly Yarborough. The Covid Contact questionnaire completed at entry. LPA entered through the central entry point where hand sanitizer and visitor symptom screening was conducted. Facility Mitigation plan has been approved by CCL. Infection control procedures described in the plan which were observed or reviewed by LPA include: Daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, staffing, PPE storage, use and training, and daily infection control procedures. All clients are fully vaccinated. LPA toured the facility inside and out. Required postings to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Staff were all observed wearing face coverings. Facility has multiple designated visitation areas available. LPA observed 30-day PPE and resident medication supply. Common and resident bathroom sinks are well stocked with liquid soap for hand washing. Through LPA’s observations, documentation review and interview with Administrator, the required infection control practices are found to be in compliance. No deficiencies cited on today’s inspection.the state’s words, verbatim · CDSS document, Aug 4, 2021