Copper River Retirement Group

Type of visit: Case Management - Other

On 12/12/22, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit. LPA introduced self and was allowed entrance by staff. LPA V Gorban met with Administrator, Shay Dustin and stated reason for visit. LPA arrived at the facility to conduct case management visit to relay information about Immediate Exclusion order for Staff Member #1. LPA verified with administrator that S1 has not worked in facility since some time. Administrator responded that S1 has not been with the facility for almost two years, Administrator was advised an exclusion has been ordered and issued by the Department and provided an exclusion order document for the facility stated above. Per administrator S1 was disassociated from facility personnel and report provided by LPA. No deficiencies sited during this Case Management visit. An exit interview was conducted and report signed on-site and a copy of report will be provided for the facility records.the state’s words, verbatim · CDSS document, Dec 12, 2022

Type of visit: Required - 1 Year

On 12/9/21 at 10:05 AM, Licensing Program Analyst (LPA) B. Miranda arrived unannounced to conduct an annual inspection. LPA was met by staff and stated purpose of visit. LPA was granted entry. Licensee (LIC) Shay Dustin and Administrator (AD) Clinton Arciete arrived a short time later. LPA toured the facility inside and out. COVID-19 guidelines are in place. Facility has one main entrance/exit point. Facility was observed clean and without any obstructions or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and no residents share a room. LPA checked resident's medications and observed the months supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Resident’s files have updated emergency contact information. Administrator certification is current. Kitchen was observed as clean and free of clutter. Fire extinguisher is up to date on service and in good standing. Water temperature read at 109.9 degrees Fahrenheit. LPA observed outside was clear and free from obstruction. Exit interview conducted. A copy of this report and appeal rights were discussed and emailed to email on record with "Read receipt" to confirm receipt of this report.the state’s words, verbatim · CDSS document, Dec 9, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) B. Miranda met with Licensee Shay Dustin. LPA asked Licensee if S2 was still working at the facility. Licensee stated S2 is still associated but has not worked at the facility for over 2 years. LPA asked if a noticed was received about S2 being an exclusion for the facility. Licensee stated no but someone called and left voicemail. Licensee stated she will disassociate S2 from all facilities by today 12/9/2022 No other action to be taken at this time. Exit interview conducted and report will be emailed to Licensee Shay Dustin.the state’s words, verbatim · CDSS document, Dec 9, 2022

Allegation investigated: Staff mismanaged resident's medication. Resident did not receive a proper refund.

On 1/14/22 at 2:35 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to deliver findings. LPA explained reason for inspection and was granted entry. Licensee (LIC) Shay Dustin arrived a short time later. During the course of the investigation, LPA conducted interviews, reviewed records, and made observations. Based on observations, interviews, and records review, LPA found that staff mismanaged resident's medication and resident did not receive a proper refund. R1's physician report did not order for R1's medication to be crushed or placed in R1's food. According to R1's admission agreement section VI(A)(1)(b)(2), since R1 left the facility during the first month of residency, R1 is entitled to 80% of the preadmission fee. Therefore, the above allegations are substantiated. Continue on LIC9099C. Substantiated Continued from LIC9099. Deficiencies are being cited based on LPA observations, interviews conducted, and records review in accordance with the California Code of Regulations, Title 22, see LIC9909D. Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report and appeal rights were emailed to email on record with "Read receipt" to confirm receipt of this report. LPA confirmed email on record is correct with Licensee.the state’s words, verbatim · CDSS document, Jan 14, 2022 · control 24-AS-20211026095919

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(5) · Plan of correction due date: Jan 21, 2022

87465 Incidental Medical and Dental Care (a) (a) A plan for incidental medical and dental care shall be developed by each facility...(5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: R1's physician report did not order for R1's medication to be crushed or placed in R1's food. This poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2022

Plan of correction: Licensee will submit proof of a plan to ensure crush orders are appropriately addressed during the admission intake, to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jan 21, 2022

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: According to R1's admission agreement section VI(A)(1)(b)(2), since R1 left the facility during the first month of residency, R1 is entitled to 80% of the preadmission fee. This poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2022

Plan of correction: Licensee will submit proof of a plan on how refunds will be addressed with residents and resident's responsible party following termination and proof of certified mail and check refund paid to R1 in the amount of $933.39, to CCL by POC due date.

Type of visit: Case Management - Deficiencies

On 1/14/22 at 2:35 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - deficiencies inspection. LPA explained reason for inspection and was granted entry. Licensee (LIC) Shay Dustin arrived a short time later. S1 and S2 are not fingerprint cleared. Both S1 and S2 have been working in the facility since 9/6/21. During the complaint investigation #24-AS-20211026095919, LPA found that Licensee did not immediately provide a copy of the admission agreement to R1 and R1's responsible party upon signing the admission agreement. Licensee admitted she did not provide a copy to R1 or R1's responsible party immediately upon signing the admission agreement and stated she provided the copy of the admission agreement the following day to staff to give to R1 and R1's responsible party. Deficiencies are being cited based on LPA observations, interviews conducted, and records review in accordance with the California Code of Regulations, Title 22, see LIC9909D. Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report and appeal rights were emailed to email on record with "Read receipt" to confirm receipt of this report. LPA confirmed email on record is correct with Licensee.the state’s words, verbatim · CDSS document, Jan 14, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d) · Plan of correction due date: Jan 14, 2022

87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement is not met as evidenced by: S1 and S2 are not fingerprint cleared. Both S1 and S2 have been working in the facility since 9/6/21. This poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2022

Plan of correction: Licensee immediately removed S1 and S2 from the facility during inspection. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(e) · Plan of correction due date: Jan 21, 2022

87507 Admission agreements (e) The licensee shall provide a copy of the signed and dated current admission agreement...immediately upon signing the admission agreement or modification... This requirement is not met as evidenced by: During the complaint investigation #24-AS-20211026095919, LPA found that Licensee did not immediately provide a copy of the admission agreement to R1 and R1's responsible party upon signing the admission agreement. Licensee admitted she did not provide a copy to R1 or R1's responsible party immediately upon signing the admission agreement and stated she provided the copy of the admission agreement the following day to staff to give to R1 and R1's responsible party. This poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2022

Plan of correction: Licensee will submit proof of plan of how a copy of the admission agreement will be provided immediately to residents and resident's responsible party upon signing, to CCL by POC due date.

Type of visit: Required - 1 Year

On 11/2/21 at 8:45 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an annual inspection. LPA was met by staff and stated purpose of visit. LPA was granted entry. Administrator (ADM) Paula Cubangbang and Licensee (LIC) Shay Dustin arrived a short time later. A tour of the facility was conducted. COVID-19 guidelines are in place. Facility has one main entrance/exit point. Facility was observed clean and without any obstructions or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and no residents share a room. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Residents files have updated emergency contact information. Administrator certification is current. The following deficiency was observed: 1. R1's hospital bed observed with two half length bed rails. One from head half length of bed and one from foot half length of bed. Deficiency is being cited based on LPA observations, record review, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. Exit interview conducted. A copy of this report and appeal rights were discussed and emailed to email on record with "Read receipt" to confirm receipt of this report.the state’s words, verbatim · CDSS document, Nov 2, 2021