Paintbrush Assisted Living and Memory Care

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPA) Katie Brown and Lissett Padgett arrived unannounced to conduct the required Annual inspection. LPA met with Administrator Jennifer Vasquez Administrator (AD) and explained the purpose of the visit. Facility was toured with Memory Care Director Traci Horn (MCD). During this visit, LPAs toured the facility inside & out. Resident rooms contained required furnishings and lighting. LPAs observed required items in bathrooms with hot water measuring between 110.1 to114.4 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPAs observed required food supply and paper products. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors, delayed egress gate was found to be in working order. First aid kits are located throughout the building and found to contain required items. Fire Extinguishers are located throughout the facility and were serviced in 2023. Smoke and Carbon Monoxide detectors are tested annually with Jorgensen fire safety company. LPAs conducted resident and staff file reviews and interviews. Administrator’s re-certification was confirmed to be in pending status and was received by the Department as required. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. See LIC 809C for continuation of this report. An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Resident Care Director, Melinda Ocaranza, whose signature on this form confirms receipt of these documents. LPA requested the following updated forms faxed to CCLD by 10/19/2023: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Emergency Disaster Plan LIC610E, Infection Control Plan review page, Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coveragethe state’s words, verbatim · CDSS document, Oct 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(C) · Plan of correction due date: Oct 13, 2023

87465 Incidental Medical and Dental Care (h)The following requirements shall apply.....: (1) Medications shall be centrally stored under the following circumstances: (C) ...Because of potential dangers related to the medication itself, ...the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement was not met as evidenced by: Licensee did not ensure medications were properly stored and/or inaccessible to residents in care. Per R4's physician report, all medications including PRN should be inaccessible. LPA's observed multiple medications in the residence. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: AD has agreed to remove all medications from R4's room. A written statement will be submitted by POC date that states the plan to inservice staff and ensure medications are inaccessible to R4. Additionally an audit of residents rooms will be conducted.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: Oct 23, 2023

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: Licensee did not ensure R1 and R3 Physician's Report were updated as required. This poses an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: AD has agreed to submit a copy of updated Physician Report via email to CCLD by POC Date. Additionally, AD has agreed to conduct an audit of resident files to ensure compliance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Oct 13, 2023

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 was clean, safe and sanitary. LPA observed mold in the ice machine.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: AD has agreed to perform a deep clean of the ice machine and send picture via email to CCLD by POC date. Additionally, a ice machine cleaning procedure will be implimented to include routine cleaning.

Allegation investigated: Personal Rights

Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct a subsequent complaint visit and deliver investigation findings. LPA met with and explained the purpose of the visit with Administrator, Jennifer Vasquez. Based on interviews conducted, the facility limited Resident (R1’s) private visitation based on the request of R1’s Power of Attorney (POA). R1’s visitation was permitted only in common areas. A record review revealed that R1’s POA documents do not specifically address authority over visitation. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report and Appeal Rights were discussed and left with Jennifer Vasquez, whose signature on this form confirms receipt of these documents. Substantiatedthe state’s words, verbatim · CDSS document, Mar 15, 2023 · control 24-AS-20221114164307

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Mar 27, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities... shall have all of the following personal rights: (11) To have their visitors,... permitted to visit privately during reasonable hours and without prior notice... This requirement was not met as evidenced by: Licensee did not ensure that R1’s visitors were permitted to visit privately. R1’s visitation was restricted by the facility. R1 was allowed visitation with family in common areas, not during mealtimes. This poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 15, 2023

Plan of correction: AD has agreed to provide in-service to Directors and care staff regarding personal rights, specifically visitation. AD will provide proof of in-service via sign in sheet to CCLD by the due date.. Sign in sheet will include Inservice topic, date, name and signature of each attendee, and trainer.

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.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Katie Brown conducted a Case Management – Incident visit at the facility. LPA met with and explained the purpose of the Case Management with Administrator (AD) Jennifer Vasquez. The purpose of the visit is to follow up on the following incidents reported to CCLD by the facility. LPA conducted record review and interviews. 1. SOC 341 and Special Incident Report (SIR) were submitted resulting in R2 reporting an altercation with Staff (S1) on 1/4/23. 2. SOC 341 and SIR were submitted resulting in R3 experiencing a fall on 11/12/22. 3.SIR was submitted which reported a medication error which occurred on 1/17/23 involving Resident (R1). Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report and Appeal Rights were discussed and left with Jennifer Vasquez, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 15, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Mar 15, 2023

87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them... as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met as evidenced by: Licensee did not ensure that a facility trained Med Tech assisted a resident with medication safely and effectively as prescribed by the Physician. S1 gave R1 a routine medication as a PRN on 1/14/23 and 1/15/23. This poses an immediate health, safety or personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Mar 15, 2023

Plan of correction: DEFICIENCY CLEARED - 0n 2/17/23 received additional Medication Management and Medication Error Prevention training. Additionally,Administrator has agreed to provide an in-service to all staff that assist residents with self administration of medications on error prevention. AD will provide proof of in-service via sign in sheet to CCLD. Sign in sheet will include Inservice topic, date, name and signature of each attendee, and trainer. To be submitted by 3/27/23 to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87466 · Plan of correction due date: Mar 27, 2023

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning….When changes such as… a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidenced by: Licensee did not ensure that R1’s Responsible Party RP) was notified after medication was not given according to Physician orders on 1/15 and 1/16/23. There is no documentation that this notification was provided to RP. This poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 15, 2023

Plan of correction: AD has agreed to provide an in-service to Directors and staff responsible for notification and documentation requirements. AD will provide proof of in-service via sign in sheet to CCLD. Sign in sheet will include Inservice topic, date, name and signature of each attendee, and trainer by the due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management visit. LPA met with and explained the purpose of the visit with with Administrator (AD) Jennifer Vasquez. The purpose of the Case Management visit is to follow up on the following reports submitted by the facility: 1. Special Incident Report (SIR) submitted 11/8/22 regarding Resident R1 resulting in injury of unknown origin after a hospital stay. During the visit, LPA observed R1, conducted interviews and a record review of R1's file. 2. Facility submitted a SOC 341 and SIR for Resident R2 on 11/18/22 which resulted in a fall. Resident was sent to the hospital for evaluation and returned with no now orders and no injury noted. During the visit, LPA met with and interviewed R2, conducted interviews and a record review of R2's resident and hospice file. There were no citations issued during this Case Management visit. An exit interview was conducted, and a copy of this report was left with Jennifer Vasquez, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Nov 21, 2022

Allegation investigated: Staff refused to provide resident with copies of his monthly payment statements

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the 10-day complaint investigation visit. LPA met with and explained the elements of the allegation with Kim Santos, Business Office Manager (S1). During the course of the investigation LPA conducted interviews as well as reviewed Resident (R1’s) facility file. Based on interviews and record review, it is determined that the allegation: Staff refused to provide resident with copies of R1’s monthly payment statements is UNFOUNDED. S1 has spoken to R1 and mailed documents including “Resident Detail Ledger” which includes a description of services and payments to the address R1 provided. R1’s Responsible Party confirmed that the facility has provided requested documents. This agency has investigated the complaint. We have found that the complaint was unfounded, therefore we have dismissed the complaint. No citations were issued during this visit. An exit interview was conducted and a copy of this report was provided to Kim Santos. Unfoundedthe state’s words, verbatim · CDSS document, Aug 17, 2022 · control 24-AS-20220809115404

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: Resident sustained a UTI while in care Resident fell while in care and sustained a fracture

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint investigation. LPA met with and explained the elements of the allegations with Administrator (AD) Jennifer Vasquez. A Record review of Resident (R1’s) file was conducted and did not reveal that R1 had a history of or specific care needs related to UTI. Interviews conducted reveal that R1 experienced increased confusion and care needs during the last weeks at the facility. Based on record review and interview, it cannot be determined that there was a lack in care or supervision by the facility that would have caused R1 to experience a UTI. 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. The allegation is UNSUBSTANTIATED. See LIC9099-C for Continuation Unsubstantiated Record review of R1’s file and interviews reveal that R1 was experiencing increased confusion. The facility had met with and planned with R1’s Responsible Party to move R1 from Assisted Living to Memory Care upon return from a hospitalization due to recent change of condition. Facility Narrative Charting show that the facility was in communication with the family regarding falls and interventions put in place. Based on record review and interview, it is not determined that the resident sustained a fracture due to lack of care and supervision by the facility. 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. The allegation is UNSUBSTANTIATED. No deficiencies cited. A copy of this report was provided, and an exit interview was conducted with AD.the state’s words, verbatim · CDSS document, Jul 20, 2022 · control 24-AS-20220215111030

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Infection Control Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Jennifer Vasquez. LPA toured the facility inside and out with AD, including randomly selected resident apartments. Infection control procedures which were observed and/or reviewed by LPA include: Daily symptom screenings for staff, residents and visitors, resident and staff vaccination, testing, visitation requirements, quarantine/isolation procedures, staffing plan, PPE and daily infection control procedures. Sanitizer is available throughout the facility. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed 30-day supply of PPE, cleaning and disinfecting products were observed and locked. LPA observed 2-day perishable and 7-day nonperishable food supply. AD has agreed to post additional hand washing and symptom related signs in restrooms and common areas. No deficiencies cited during this inspection. A copy of this report was provided, and an exit interview was conducted with AD. LPA requested the following updated forms by 7/27/22: LIC 308, LIC 309, LIC 402, LIC 500, LIC 610E. Infection Control Plan has been submitted.the state’s words, verbatim · CDSS document, Jul 20, 2022

The state marks this report as 4 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff not notifying resident's Authorized Representative of incident involving resident.

LPA Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver investigation findings. LPA met with and explained the purpose of the visit with Resident Care Director (RSD) Marilyn Couzens. During the visit, LPA obtained/reviewed resident and facility files as well as interviewed staff. Record Review revealed that S1 received verbal counseling due to not following facility reporting procedure to inform resident authorized representative after an incident like a fall or hospitalization has occurred. Based on interview and record review of the facility Employee Counseling Form The preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care. A copy of this report including Plan of Correction and Appeal Rights were provided and an exit interview was conducted with the RSD. Substantiated ALLEGATION 2: Staff interviews revealed that when a change in skin condition or visible injury is observed there is a reporting protocol in place. Based on records review of facility Narrative Charting it was observed that staff have noted resident changes or injury as well as increased monitoring. ALLEGATION 3: Interviews and records review were conducted which reveal that R3 is resistive and combative with staff who are assisting in resident daily care. Based on interviews and Needs and Service Plan review, it is documented that R3 at times yells at or becomes agitated at other residents. There were no staff that confirmed ever witnessing R3 abuse or cause physical injury to another resident. ALLEGATION 4: Interviews and records review confirm that residents fall in care. Based on interviews, staff explained the facility fall procedure when a resident is found having fallen. During interview, there were no staff who confirmed or identified specific residents that experience numerous falls without interventions put in place. Records review indicate that Needs and Service Plans note when a resident is at risk of falls, including interventions. ALLEGATION 5: Interviews of staff members reveal that staff have not been observed yelling at residents. Based on interviews, staff report that there are residents that are hard of hearing and someone could interpret this as yelling. Based on interview of the Memory Care Director (MRD) reveals that staff are educated on Personal Rights, which include approach and how to speak to residents effectively. ALLEGATION 6: Interviews and record review of facility Narrative Charting reveal that most of the residents in MC do not use a pendant to call for assistance. Based on interviews, residents in MC do not understand or remember how or when to use the pendant correctly. Staff report that increased resident checks, knowing resident habits and behaviors and encouraging residents to be in common areas help ensure that residents receive assistance when needed. It was observed in facility charting notes that increased monitoring is noted after incidents experience a fall, illness or change of condition. ALLEGATION 7: Interviews and record reviews were conducted and reveal that staff have been educated on how to properly transfer and/or assist a resident up. Based on staff interview, pulling a resident by their arms is not how they are trained. Records review of facility in-service indicates that this education has occurred. SEE 9099-C FOR CONTINUATION ALLEGATION 8: Interviews and record review indicate that there are multiple ways staff can ensure that the resident rooms are free of odor. Based on interviews, there is a House Keeping schedule and assignment for every resident room. A work order can be made to request carpet cleaning and staff have access to cleaning supplies after House Keeping hours. Records review revealed that House Keeping staff maintain and turn in a log that documents that scheduled cleaning has been completed. ALLEGATION 9: Interviews and records review reveal that the facility receives scheduled monthly and “as needed” Exterminator services. Based on interview of the Environmental Services Director (ESD), the pest control provides service to the exterior and interior of the facility, including the kitchen. Along with the monthly pest control service, daily pest prevention measures are in place in the kitchen as well. Records review confirms that monthly service as well as “as needed” pest control services are conducted. ALLEGATION 10: Interviews and record review were conducted. Based on Interview, R4 leaves the facility for scheduled dinner with family weekly. Staff interviews reveal that since Covid “shut downs” R4 has experienced a general decline, increased agitation and anxiety due to missing family visits. Staff interviewed believe that R4 is able to communicate if in pain. Multiple staff members were interviewed, and it was not confirmed that an abuse allegation was reported. Directors interviewed denied that a report was provided to them. Based on interviews and records reviews conducted by The Department, the allegations 1-10 as listed above are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. A copy of this report was provided and an exit interview was conducted with RSD.the state’s words, verbatim · CDSS document, May 17, 2022 · control 24-AS-20220113102916

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: May 17, 2022

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: The Licensee did not ensure that changes in resident condition (ie; fall or hospitalization) were documented and brought to the attention of the resident's physician and the resident's responsible person as noted on Employee Counseling Form dated 6/15/21 for S1. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, May 17, 2022

Plan of correction: Facility RSD has agreed to provide an in-service to Med Techs and Nurses who are responsible for notifying resident authorized representatives when a incident occures. An in-service sign in sheet as well as materials used for education will be provided to LPA by 5/31/22

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a Case Management visit. LPA met with Resident Care Director Marilyn Couzens, LVN (RCD) and explained the purpose of the visit. The facility submitted a SOC341 and Special Incident Report (SIR) on 2/16/22. The SIR reported an incident that occurred in the parking lot of the facility 2/14/2022 between a former staff member S1 and current staff member S2 Resident R1 was present at the time of the incident. No harm or injury occurred as a result of the incident. The facility called 911 and a Police Report was filed. LPA obtained a copy of the Police Report. LPA interviewed R1 and S2 during this visit. No citations are issued during this visit. A copy of this report was provided, and an exit interview conducted with RCD.the state’s words, verbatim · CDSS document, Feb 25, 2022

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Health & Safety Inspection in conjunction with opening a complaint. The inspection was conducted vis tele-visit due to Covid 19 precautions. LPA met with and explained the purpose of the visit with Administrator Jennifer Vasquez. LPA conducted a tour of the facility with Administrator. No immediate Health and Safety concerns were observed. Resident apartments were randomly chosen throughout the tour to be observed by LPA. No deficiencies were cited during this inspection. An exit interview was conducted with the Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 14, 2022

Allegation investigated: Staff are mismanaging residents medication Staff did not provide basic laundry services in a timely manner Facility is not abiding by residents admissions agreement

LPA Katiie Brown arrived to the facility unannounced for a subsequent complaint visit and to deliver the investigation findings to the facility. LPA met with Administrator, Jennifer Vasquez. During the visit, LPA interviewed Staff (S6) and Staff (S7). The Department has investigated the complaint alleging: Staff were mismanaging residents medications. A record review of R1’s Physician’s ordered medications and Medication Administration Record (MAR) was completed. Based on staff interviews and record reviews conducted of R1’s ordered medications, MAR and facility medication procedure it is determined that staff mismanaged R1’s medications and medications were not assisted with and given according to Physician’s orders. The preponderance of evidence standard has been met, therefore the allegation has been found to be SUBSTANTIATED. See 9099-C for Continuation Substantiated The Department has investigated the complaint alleging: Staff did not provide basic laundry service in a timely manner. Based on record review of the facility Laundry and House Keeping Log and Admissions Agreement, interview and pictures provided by the Reporting Party it has been determined that the facility did not provide basic laundry service in a timely manner. Documentation shows that scheduled services were provided but that soiled linens and clothing were discovered and not removed timely. The preponderance of evidence standard has been met, therefore the allegation has been found to be SUBSTANTIATED The Department has investigated the complaint alleging: Facility is not abiding be residents admissions agreement. Based on interview and review of the Admissions Agreement signed 4/9/2021, it was discovered that a 30 Day reassessment was not conducted for R1. According to the Reporting Party, this reassessment would have determined additional needs and assistance required for R1. The Department confirmed through interview that the reassessment was not conducted as stated in the Admissions Agreement. The preponderance of evidence standard has been met, therefore the allegation has been found to be SUBSTANTIATED. Deficiencies were observed and noted on the attached LIC 809D. A Plan of Correction was developed, an Exit Interview was conducted and a copy of this report including Appeal Rights were provided to the Administrator The Department has investigated the complaint alleging: Staff did not meet residents hygiene needs. Based on staff interview, it was determined that R1 refused assistance with hygiene and bathing much of the time. Record review of R1’s Needs & Service Plan, Physician's Report and Service Plan document that R1 was independent or required standby assist in providing own hygiene tasks. 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. The allegation is UNSUBSTANTIATED The Department has investigated the complaint alleging: Residents room is malodorous. Based on interviews conducted of other residents, services are provided to eliminate odors upon request. During interview with staff, it was reported that the room sometimes smelled like R1’s pet had soiled carpet or not been taken outside timely. It was reported that the carpet was cleaned upon request. Based of interview with residents and staff members as well as review of facility provided documentation of housekeeping, carpet cleaning and laundry/trash removal the Department is unable to determine if the allegation occurred. 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. The allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Sep 20, 2021 · control 24-AS-20210616140736

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Sep 21, 2021

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Licensee did not ensure that medications were taken as prescribed by the Physician. R1’s MAR confirms multiple instances where staff did not verify that medications were given according to the facility procedure. Staff interviews confirm that “if its not initialed, the medication was not given. MARs reviewed include April, May, June 2021. This results in an immediate health & safety risk for persons in care.the state’s words, verbatim · CDSS document, Sep 20, 2021

Plan of correction: Licensee has agreed to provide a current list of Med Techs and Nurses approved to provide assistance with and pass out medications along with an Inservice Training Plan to be provided to CCL by 5PM 9/21/21. Licensee has agreed to provide Staff In Service to the identified staff members as well as a copy of training materials and sign in sheet. Inservice will review medication pass and documentation procedures. In Service and supporting documentation to be provided to CCL 9/28/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(C) · Plan of correction due date: Sep 28, 2021

87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident......if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C)Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times... This requirement was not met as evidenced by: This requirement was not met as evidenced by: Licensee did not ensure that the facility provided accomidations & Service to ensure R1's soiled laundry ws removed from the apartment. Photos were provided of soiled clothing and bedding. This poses a potential health & safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 20, 2021

Plan of correction: Licensee has agreed to review the Resident Assistant job description with staff members and provide a copy of supporting documents and sign in sheet to in service/review. Documentation to be provided to CCL by 9/28/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Sep 28, 2021

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: Licensee did not ensure that all applicable terms and conditions set forth in the admission agreement were met. R1 did not receive a 30 day re evaluation/assessment as stated in the Admissions Agreement dates 4/9/21. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 20, 2021

Plan of correction: Licensee has agreed to submit in writing the new procedure and process for timely assessments to CCL by 9/28/21.

Allegation investigated: Staff allowed resident to AWOL from facility

Licensing Program Analysts (LPA) Katie Brown and Mai Yang arrived at the facility unannounced to conduct a subsequent complaint investigation. LPAs met with Administrator Jennifer Vasquez. The Department has investigated the complaint alleging: Staff allowed resident to AWOL from facility. Based on interview and record review of the Special Incident Report (SIR) dated 4/22//21, it was confirmed that Residents (R1) and (R2) left the facility through a side gate. Facility staff were notified that the gate was opened by facility notification system. The preponderance of evidence standard has been met, therefore the allegation has been found to be SUBSTANTIATED. See attached 9099-D for deficiency An exit interview was conducted and a plan of correction (POC) was developed with the Administrator. Report and Appeal Rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Sep 2, 2021 · control 24-AS-20210503142412

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208(c) · Plan of correction due date: Sep 3, 2021

87208(c) Plan of Operation A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement was not met as evidenced by: On 4/22/21 R1 and R2 left the facility unsupervised from the facility through the gate outside the Memory Care unit. This poses an immediated health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee has agreed to provide a written statement to CCL explaining the procedure to be put in place regarding Third Party Access to the facility by 9/3/21. Licensee has agreed to develop a Third Party Access procedure in which the Landscapers check in and out with a Director to ensure the gate is appropriately secured. A copy of the procedure as well as documentation of all Directors training will be sumbitted to CCL by 9/10/21.

Allegation investigated: Staff does not respond to call buttons in a timely manner

Licensing Program Analyst (LPA) Katie Brown conducted the subsequent complaint investigation visit to the facility to obtain additional information. LPA met with Administrator, Jennifer Vasquez. During the course of this visit LPA interviewed facility Administrator and obtained and/or reviewed facility records which include 7/1/21 – 7/21/21 “Pendent Report” for all residents, the July 2021 staff schedule for Assisted Living (AL) and Memory Care (MC) as well as the schedule of “Agency" staffing used. The Department has investigated the complaint alleging: Staff did not respond to call buttons in a timely manner. Based on the interview and records review of the facility “Pendent Report” dated 7/5/21, it is determined that R1’s call button (or pendent) was activated and not “cleared” by facility staff for 38 minutes resulting in R1 requiring emergency medical care. The preponderance of evidence standard has been met; therefore the allegation has been found to be SUBSTANTIATED. See attached 9099-D for deficiency An exit interview has been conducted with Administrator, Jennifer Vasquez. Appeal Rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Jul 21, 2021 · control 24-AS-20210719092518

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 22, 2021

87411(a) Personnel Requirements – General- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care… The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Licensee did not ensure resident call buttons were responded to timely. R1's call button or "pendent" was not cleared for 38 minutes 38 minutes resulting in R1 requiring emergency medical care. This poses an immediate Health and Safety Risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2021

Plan of correction: Licencee agrees to provide a written statement to CCLD describing the actions in process to adress increased staffing needs, pendent report monitoring and correction action taken with staff. Statement to also include the new staffing plan, effective date(s) and sample schedule for August 2021 to be submitted via email to CCLD by 7/22/2021. Licencee has agreed to provide RA and LVN training on the facility call button response expectations. A sign in sheet which includes date, description, staff names and signatures will be sumbitted to CCLD by 8/1/21