Magnolia Crossing

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), M. Flores arrived at the facility to conduct a case management follow up on SOC341. LPA met with Resident Care Coordinator, Krista Mildebrand (AD1) and Administrator, Constance Peters (AD). During this visit, resident file was reviews for R1. No citations were given at this time. Copy of this report was provided to AD.the state’s words, verbatim · CDSS document, Sep 12, 2023

Allegation investigated: Staff did not seek medical attention for a resident. Staff did not dispense residents’ medication as prescribed.

On 08/04/2023, Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced to deliver findings on the allegations listed above. LPA met with Facility Administrator Constance Peters announced the purpose of the inspection. Regarding the allegation staff did not seek medical attention for a resident. LPA Hurt reviewed Centrally Stored Medication Logs, Medication Administration Records, and medications for Resident 1, and Resident 2. LPA Hurt spoke with three facility staff who agreed the Medication Administration Record has several errors, and the count was not always done at the end of each shift. Based on this it is unclear if there was a medication error or if medical attention was needed for Resident 1. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Continued on 9099C.. Unsubstantiated Continued Regarding the allegation staff did not dispense residents’ medication as prescribed. LPA Hurt reviewed Centrally Stored Medication Logs, Medication Administration Records, and medications for Resident 1, and Resident 2. LPA Hurt spoke with three facility staff who agreed the Medication Administration Record has several errors, and allegedly the count was not always done at the end of each shift. Based on this it is not clear if a resident was not dispensed medication as prescribed. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No Deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Administrator Constance Peters. A copy of this report along with appeals rights provided.the state’s words, verbatim · CDSS document, Aug 4, 2023 · control 24-AS-20230724091124

Type of visit: Case Management - Other

On 08/04/2023, Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility LPA met with Facility Administrator Constance Peters and announced the purpose of the inspection. LPA Hurt reviewed the facility Medication Administration Records. LPA Hurt observed the facilities medication tracking system is unorganized, missing medication technician signatures, documents extra medication technician signatures, documents crossed out information on the Medication administration record without documenting what happened in each instance. LPA Hurt advised Administrator Constance Peters of the importance of correctly tracking, documenting, and storing all resident medications. Technical Assistance provided. Exit interview conducted with Administrator Constance Peters, and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 4, 2023

Allegation investigated: Staff using profanity toward residents Staff is falsifying resident records Staff is engaging in inappropriate activites infront of residents

Licensing Program Analyst (LPA) Darius Williams conducted an unannounced follow up visit. LPA Williams met with Administrator, Constance Peters. LPA Williams conducted interviews, observations, and record revie In regards to staff using profanity towards residents, LPA interview four residents. Resident 4, 7, and 8 reported they have not seen or heard staff use profanity toward residents. Resident 2 reported hearing someone use profanity while they were in their room, but did not see if the individual was a resident or staff or who they were speaking to. In regards to staff falsifying records. LPA spoke with Staff 1 who reported if residents decline to eat or want to eat in their room, they informs the manager. *Continued on LIC 9099-C* Unsubstantiated In regards to staff is engaging in inappropriate activities in front of residents, R5, R6, R7, and R8 all reported they have not witnessed any inappropriate behavior from staff. The Reporting Party was anonymous and no contact information was provided to the Department for follow up and clarification regarding dates, times, and individuals involved regarding the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. In regards to staff not providing residents with meals, on 7/6/2023 and 7/17/2023, LPA Williams observed staff preparing meals and residents eating in the dining hall. LPA Williams interviewed interview Staff 1 who reported meals are provided to resident in their room, if they want, and in the dining hall. Resident 5, Resident 6, Resident 7, and Resident 8 all reported knowing when meal times were and stated staff will come to their door to remind them if they do not come out to the dining hall. In regards to resident's dog disrupts other residents during the day and night time, the facility policy allows pets. During the LPA's two visit no dog was heard barking. According to the Administrator a walking program is established for the dog and the residents family will assist as needed. Administrator reported any concerns regarding the dog is brought to the attention of the resident and their family. The Reporting Party was anonymous and no contact information was provided to the Department for follow up and clarification regarding dates, times, and individuals involved regarding the allegations. This agency has investigated the complaint alleging multiple residents developed stage 4 pressure injury because staff do not reposition residents, staff not providing residents with meals, resident's dog disrupts other residents during day and night time. We have found that the complaint was UNFOUNDED, meaning it could not have happened, and/or is without a reasonable basis, therefore we have dismissed the complaint.the state’s words, verbatim · CDSS document, Jul 17, 2023 · control 24-AS-20230620122450

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Darius Williams conducted a visit at the facility in response to a resident document received. LPA Williams met Administrator, Constance Peters and discussed the purpose of the visit. LPA Williams reviewed medical assessments for Resident 1 (R1) and Resident 2 (R2), who are admitted to the memory care facility. R1's recent medical assessment was dated 1/14/2022 and R2's recent medical assessment was dated 5/23/22. Based on Title 22 regulation, R1's medical assessment had to be renewed by 1/14/2023 and R2's by 5/23/2023. Administrator reported the medical assessment would be completed by 7/14/2023. Based on record review a deficiency is being cited on the attached LIC 809-D page. An exit interview was conducted and a copy of this report and appeal rights will be provided via e-mail.the state’s words, verbatim · CDSS document, Jul 6, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jul 14, 2023

(c) Licensees who ... retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment ... done at least annually, ... This requirement was not met evident by: Based on LPA's record review, the Licensee did not ensure 2 residents in Dementia care had an annual medical assessment completed, which cause a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 6, 2023

Plan of correction: The Administrator agreed to schedule medical assessments to be completed for 2 residents by POC due date of 7/14/2023. Administrator will provide medical assessments to the Department for proof of completion.

Allegation investigated: Staff provides care to residents while under the influence of marijuana. Staff do not ensure that infection control practices are maintained when handling medication.

Licensing Program Analyst (LPA) L. Xiong conducted the complaint investigation visit to the facility. LPA met with Administrator Constance Peters and informed her the purpose of the visit. During this visit LPA delivered investigation findings regarding the above allegations.The Department has investigated the complaint alleging: Staff provides care to residents while under the influence of marijuana, and Staff do not ensure that infection control practices are maintained when handling medication. Based on the interviews conducted and/or records review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 23, 2023 · control 24-AS-20230619090724

Allegation investigated: Staff are restricting residents vistors.

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the above allegation. LPA Hurt met with facility Administrator Constance Peters and explained the purpose of today's visit. Regarding the allegation staff are resricting residents vistors. Witness 1 attempted to visit Resident 1 on April 19, 2023 and was told by facility staff he would not be allowed to visit, or speak to Resident 1 without supervision. LPA Hurt spoke with Resident 1 who stated he was ok with Witness 1 visiting him, and he does not want to deny anyone from visiting him. LPA Hurt reviewed the Power of Attorney documents for Resident 1, and there is no section mentioning visitors or restriction of specific visitors.. Resident 1's Power of Attorney has not provided any documents proving anyone is legally ordered to stay away from Resident 1. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. The following Deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Administrator Constance Peters, and a copy of this report provided. Substantiatedthe state’s words, verbatim · CDSS document, Jun 2, 2023 · control 24-AS-20230424172045

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(b)(7) · Plan of correction due date: Jun 3, 2023

87468.1 Personal Right of Residents in All Facilities (b)(7)(b) All residents in all residential care facilities for the elderly shall be protected from all of the actions specified in this subsection. A licensee or facility staff may not take any of the following actions, which also includes taking these actions wholly or partially on the basis of the actual or perceived sexual orientation, gender identity, gender expression, or human immunodeficiency virus (HIV) status, of a resident: Restrict a resident’s right to associate with other residents or with visitors, including the right to consensual sexual relations. The following requirement has not been met as evidenced by: Resident 1 is able to make their own decisions, and does not want to deny anyone access to visiting them. The facility staff did not allow Witness 1 visitation with Resident 1, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2023

Plan of correction: Administrator will conduct "Personal Rights" Training with facility staff and send proof to LPA by 06/03/23 POC date.

Allegation investigated: Staff did not ensure facility ovens are working properly

On 5/31/23 at 8:20 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an initial 10-day complaint inspection. LPA explained reason for inspection and was granted entry by Administrator (ADM) Constance Peters. LPA conducted interviews and toured the three buildings. LPA observed each building with a kitchen that has a double oven. LPA observed all six ovens operational and heating up. The allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report was given to Administrator, whose signature confirms receipt of this report. Unfoundedthe state’s words, verbatim · CDSS document, May 31, 2023 · control 24-AS-20230525082016

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 - Other

On 5/31/23 at 9:20 AM, Licensing Program Analyst (LPA) Malia Thao conducted an unannounced case management - other inspection. LPA explained reason for inspection and met with Administrator (ADM) Constance Peters. During the inspection for complaint #24-AS-20230525082016, LPA found that ADM and S1 was not associated to the facility. ADM began working on 5/22/23 and S1 began working on 5/24/23. Facility completed a transfer of criminal record clearance on the Guardian website for both ADM and S1 during the inspection. No deficiencies cited during this inspection. Licensee was present during the beginning of the inspection and advised all paperwork for the change of Administrator will be submitted to CCL within the next 3 weeks. LPA advised the annual renewal fees have not been paid current. Licensee stated he will inform the Director of Operations. LPA advised ADM that the annual renewal fees must be paid within the next 2 weeks. Exit interview conducted. A copy of this report was given to Administrator, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, May 31, 2023

Allegation investigated: Staff administering medication while under the influence

On 02/21/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations, LPA introdcued self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Administrator, Lai Saeteurn. During this investigation, LPA reviewed records and interviewed facility staff. Based on interviews conducted, the allegation: Staff administering medication while under the influence is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficeincies issued during this inspection. Exit interview conducted. A copy of this report was dicussed and provided to Administrator, Lai Saereurn, whose signature on this form confirms receipt of this document. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 21, 2023 · control 24-AS-20230109110932

Allegation investigated: Staff inappropriately handled residents Staff used inappropriate words towards resident

On 6/29/22 Licensing Program Analyst (LPA) M. Garza arrived at facility unannounced to deliver findings on complaint. LPA was met by Administrator, Frances Hernandez. LPA explained reason for visit and was COVID pre-screened. LPA was permitted entry into facility. LPA toured facility inside and out. A health and safety check on residents were observed in common areas and in rooms. During the investigation interviews were completed with staff and Administrator. S3 confirmed that S1 "was not approriately transferring R1" and that S1 "was agitated with R1" and "mad about having to work with them because R1 could be difficut at times". S1 was "aggressive in the way that they would sometimes talk to residents". Administrator stated "due to COVID staff was working in areas that they normally did not work and knew some of the staff were burnt out". The allegations listed above are SUBSTANTIATED. The poponderance of evidence standard has been met. Per CA Title 22,the state’s words, verbatim · CDSS document, Jun 29, 2022 · control 24-AS-20211021101417

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 12, 2022

87468.1 Personal Rights of Residents.. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidence by: LPA's review of records, interviews with staff and Administrator which showed staff were shorthanded, working in areas they normally didn't and were "burnt out". S1 was transferring/talking to residents inappropriately. This posses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 29, 2022

Plan of correction: Administrator stated that they will complete staff traiining on Personal Rights with each household, with Ombudsman and will provide CCL copy of training materials and a sign ni sheet by POC date.

Allegation investigated: Resident fell resulting in an injury due to care and supervison. Staff not seeking medical attention for resident in a timely manner. Resident's medication was not properly administered by staff. Staff forced resident to take medication.

On 6/29/22 Licensing Program Analyst (LPA) M. Garza arrived at facility unannounced to deliver findings on complaint. LPA was met by Administrator, Frances Hernandez. LPA explained reason for visit and was COVID pre-screened. LPA was permitted entry into facility. LPA toured facility inside and out. A health and safety check on residents were observed in common areas and in rooms. During investigation records were reviewed and interviews with staff were completed. Administrator confirmed that R1 had a history of falls. R1 was on hospice and was not sent out for these falls. Injuries were treated by hospice. Although the allegation occurred it was not due to lack of care and supervision of resident. LPA reviewed R1’s file for medications that were being taken. MARS were reviewed for the months of October through December 2021 which shows that R1 was receiving medications as prescribed. R1’s file contained a prescription from R1’s PCP to crush R1’s medications. Although the allegations may or may not have occurred the perponderance of evidence does not meet the Departments standard. The above allegations are UNSUBSTANTIATED. Exit interview completed. A copy of this report was given. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 29, 2022 · control 24-AS-20211021101417

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 2/22/2021, Licensing Program Analyst, M. Garza arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA was greeted by Administrator, Frances Hernandez. Due to facility having positive COVID staff/residents LPA conducted video tele-visit. LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. Residents observed in common area and in room. Mitigation plan was reviewed and approved. COVID-19 procedures described in the plan include required postings, symptoms screenings (for staff, persons in care and visitors), testing, quarantine/isolation cohorts, infection control plan to include donning and doffing of Personal Protective Equipment. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages. LPA toured the facility inside and out. Required postings of signs to include hand washing, coughing etiquette and physical distancing were observed throughout the facility. Staff observed coming out of buildng without face coverings. Facility has designated visitation areas. Covered trash bins were not observed. LPA observed a 30 day supply of PPE and resident medications. Sinks are well stocked and liquid soap for hand washing and paper towels for hand drying were observed. Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices are found to be in compliance. No deficiencies cited on todays inspection. TA's given for masking and trash bins. A copy of this report will be emailed. A delivered and read receipt serves as confirmation.the state’s words, verbatim · CDSS document, Feb 22, 2022