Westmont of Fresno

Allegation investigated: Facility does not have an administrator.

On 11/07/23 Licensing Program Analyst (LPA) V Gorban visited the facility stated above to deliver findings. LPA met with Business Office Director Jennifer Fowler, explained the purpose of the visit. Administrator Patrick Frazier was notified of licensing visit. LPA toured the facility inside and out, observed residents in care and discussed findings to allegations. Allegation: facility does not have an administrator. During this investigation department reviewed facility file and interviewed administrator and staff. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have found that the complaint was unfounded, therefore we have dismissed the complaint. Exit interview conducted, report signed and copy of this report provided for facility records. Unfoundedthe state’s words, verbatim · CDSS document, Nov 7, 2023 · control 24-AS-20230915102336

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: Facility alarm is in disrepair

On 9/28/23 Licensing Program Analyst (LPA) V Gorban visited facility stated above to deliver findings. LPA met with Administrator (AD) Jennifer Fowler explained the purpose of the visit and discussed findings. Allegation: Facility alarm is in disrepair During complaint investigation LPA tested facility alarm and appears is operational. LPA reviewed facility files and interviewed staff. Although the allegation “Facility alarm is in disrepair” 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. Exit interview conducted, report signed and copy provided to AD for facility records. Unsubstantiated Allegation: Staff did not prevent resident from wandering from facility. Based on LPAs observations and interviews which were conducted and record reviews, the resident was found outside sleeping on the ground and staff was not aware of resident location. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.” Exit interview conducted, report signed, and copy of this report with appeal rights provided to Administrator for facility records.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 24-AS-20230711084903

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Sep 29, 2023

1569.2 (c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered... This was not observed as evidenced by: Based on interviews and record reviews R1's mental health, physical health , and safety was jeopardize when she end up unsupervised outside the facility in the middle of the night time. This poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Administrator will provide staff in services on resident supervision, mental health, and safety. Training for dementia will be provided to staff and notify Licensing by 09/29/23

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(2) · Plan of correction due date: Oct 16, 2023

87705 Care of Persons with Dementia. (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This was not observed as evidenced by: Based on interviews and record reviews R1 was able unsupervised leave facility building unsupervised in the middle of the night. Facility did not provide safety measures to address wondering behavior which cause R1 being unsupervised for unknown amount of hours and outside of the facility in the middle of the night.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Facility will provide staff training on dementia and wandering. Facility will provide completed training to Licensing by 10/16/23

Allegation investigated: Facility is in disrepair. Staff did not ensure that a resident's room is maintained at a comfortable temperature.

On 9/28/23 Licensing Program Analyst (LPA) V Gorban visited facility stated above to deliver findings. LPA met with Administrator (AD) Jennifer Fowler explained the purpose of the visit and discussed findings. Allegation: Facility is in disrepair. Allegation: Staff did not ensure that a resident's room is maintained at a comfortable temperature. During this investigation LPA observed facility, reviewed history files, facility files, and interviewed facility staff. Based on investigation listed above these allegations 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, therefore the allegations are Unsubstantiated. Exit interview conducted, report signed and provided to AD for facility records. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 28, 2023 · control 24-AS-20230705085754

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 7/28/2023, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit the facility that was reported to Licensing on 7/24/23. LPA introduced self and was allowed entrance by staff. LPA Gorban met with Administrator Erik Schuk. LPA toured facility inside and out, observed residents in dining room during breakfast. LPA Gorban reviewed facility residents’ files, interviewed staff and administrator. LPA attempted to interview residents R1 and R2. LPA requested following facility files: staff schedule, residents files, facility policy and procedures, and staff training. No deficiencies cited during this Case Management visit. Exit interview was conducted, report signed on-site, and a copy of this report was provided for facility records.the state’s words, verbatim · CDSS document, Jul 28, 2023

Type of visit: Case Management - Incident

On 7/18/23 Licensing Program Analyst, (LPA) V Gorban conducted a case management visit to the facility stated above regarding incident involved resident (R1) occurred in the facility reported on 6/14/2023, Incident was not reported until 6/26/23. LPA stated purpose of the visit and met Administrator Erik Schuk. LPA toured facility with AD inside and out. LPA reviewed facility files and interview staff. LPA verified facility staff (S1) is currently not working in the facility. LPA interviewed AD and verified with AD that S1 has not been worked in facility since 6/16/23. Administrator provided disassociated S1 from facility personnel report provided by AD to LPA Gorban during visit. Exit interview conducted, report signed, printed with appeal rights. Deficiency cited on attached 809 Dthe state’s words, verbatim · CDSS document, Jul 18, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 18, 2023

87211(a)(1) Reporting Requirements A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by LPAs record review. Licensee did not report incident of R1 which poses potential health and safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 18, 2023

Plan of correction: For plan of correction (POC) Administrator agrees to review and submit a written statement on how this regulation will be met in the future by POC due date 7/30/23

Allegation investigated: Facility staff did not dispense medication as prescribed

On 7/05/23, Licensing Program Analyst (LPA) V Gorban conducted the subsequent complaint investigation visit to the facility. LPA met with Michelle Gonzalez, Residential Services Director (RSD), explained the purpose of the visit, and discussed allegation findings. Administrator Erik Schuk was not available. Allegation: Facility staff did not dispense medication as prescribed During the course of investigation of this complaint LPA interviewed facility staff, obtained and reviewed facility records. Medication was not provided to resident as prescribed. Facility file had medication on record but was not provided to R1 as prescribed. Based on observations, interviews which were conducted, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. Exit interview conducted with RSD. Copy of this report signed and provided with appeal rights for facility records. Substantiatedthe state’s words, verbatim · CDSS document, Jul 5, 2023 · control 24-AS-20230404100407

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jul 5, 2023

87465(c)(2) Incidental Medical and Dental Care: ....Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews and record reviews facility staff failed to give medication as prescribed and resident missed medications, which poses an immediate Health and Safety risc to the resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Facility will ensure to educate staff and provide medication training. All in service medication training will be completed and copy provided to CCL for the plan of correction by 07/07/23.

Allegation investigated: Facility staff did not assist resident in a timely manner

This document is amended of the original report. On 7/05/23, Licensing Program Analyst (LPA) V Gorban conducted the subsequent complaint investigation visit to the facility. LPA met with Residents Services Director (RSD), Michelle Gonzalez, explained the purpose of the visit and discussed allegation findings. Administrator Erik Schuk was not available. Allegation: Facility staff did not assist resident in a timely manner During the course of investigation, observation, records reviews and interviews, 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. Exit interview conducted with RSD. Copy of this report signed and provided for facility records. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 5, 2023 · control 24-AS-20230404100407

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: Facility does not have adequate staff to meet the needs of the residents Facility staff are not properly handling resident's medications.

On 06/08/2023, Licensing Program Analyst (LPA) Gorban arrived at the facility unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and was greeted by receptionist. LPA requested to meet with the Administrator. LPA toured facility, reviewed residents’ records, observed residents in common area. LPA discussed finding with Administrator Erik Schuk. Allegation: Facility does not have adequate staff to meet the needs of the residents. During the investigation, LPA interviewed residents and staff, conducted a facility tour and reviewed records. During LPAs visit, based on observation facility had substantial number of staff. Based on records review and facility provided proof of medications, elderly and dementia training, the allegation: Facility does not have adequate staff to meet the needs of the residents is 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. Unsubstantiated Allegation: Facility staff are not properly handling resident's medications. During the investigation, LPA interviewed residents and staff, conducted a facility tour and reviewed records. LPA observed medication technicians handling residents’ medication while visiting facility. Based on observation, record review and interviews conducted with residents and staff, the allegation is 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 this allegation is UNSUBSTANTIATED. Exit interview conducted. Report signed and copy of this report provided to Erik Schuk Administrator for facility records.the state’s words, verbatim · CDSS document, Jun 8, 2023 · control 24-AS-20230321164409

Type of visit: Case Management - Other

This is an amended report issued on 3/21/2023. On 3/24/23 Licensing Program Analyst (LPA) V Gorban visited facility stated above. LPA met with Assistance Administrator Jennifer Fowler , stated purpose of the visit and allowed entry in the facility followed infection prevention protocol. LPA visited facility to follow up on incident reported to department on 03/01/23. Erick Schuk was not available to assist LPA. LPA attempted to interview resident (R1). Facility reports states R1 has dementia and unable to confirm return of the ring since R1 was not aware ring was missing in the first place. LPA contacted family member, who is R1’s daughter. Family member and responsible party (RP) confirmed that ring returned to family, and they keep in their possession. Administrator stated that S1 last day of work was on 03/02/23. Administrator stated that S1 was terminated on the same day. Facility staff disassociated S1 from LIC500, facility roster. Exit interview conducted, report signed by facility Assistance Administrator Jennifer Fowler and provided for facility records. Original document was returned to LPA on 3/24/2023.the state’s words, verbatim · CDSS document, Mar 21, 2023

Type of visit: Case Management - Incident

On 10/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Case Management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Erik Schuk The purpose of this visit is to follow up on an incident report that was submitted to the Fresno CCL office. It was reported that on 09/13/2022 a hospice resident received a medication that had been discontinued. A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6, on the attached 809D. A civil penalty in the amount of $250 is being assessed for repeat violation. Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Erik V. Schuk, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Oct 13, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 14, 2022

87465 Incidental Medical and Dental Care (a)(4): The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review, the facility did not ensure the requirements for section 87465(a)(4) were met when facility staff administered a medication to R1 that had been discontinued, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 13, 2022

Plan of correction: Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements of this section are met to the Fresno CCL office by the POC due date.

Allegation investigated: Staff did not respond to egress alarm timely, resulting in resident exiting memory care, falling and sustaining an injury

On 10/3/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Erik Schuck During the course of the investigation, LPA conducted a facility tour, interviewed staff, and reviewed records. Based on interviews and records review, staff did not respond timely to the egress alarm, resulting in R1 exiting the facility, falling, and sustaining a head injury requiring that medical attention be sought. Review of the facility Alarm Event Report indicates that staff responded to the egress alarm approximately 34 minutes later. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the allegation: Staff did not respond to egress alarm timely, resulting in resident exiting memory care, falling and sustaining an injury is SUBSTANTIATED. CONTINUED TO 9099C. Substantiated A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 9099D. The issuance of civil penalties is currently under review. The details of civil penalties will be outlined in a future report to the facility, if any. Exit interview conducted and a Plan of Correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Erik Schuk whose signature on this form confirms receipt of these documentsthe state’s words, verbatim · CDSS document, Oct 3, 2022 · control 24-AS-20220729113420

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 4, 2022

87468.2(a)(4): (a) In addition to the rights listed in Section 87468.1...residents...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 evidenced by: Based on interviews and record review, the licensee did not ensure R1's needs were met when R1 was able to leave the facility undetected resulting in a fall outside of the facility which is an immediate health and safety risk to residents/clients in carethe state’s words, verbatim · CDSS document, Oct 3, 2022

Plan of correction: Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for this section are met including the facility's plan to train all staff on emergency prototcols to the Fresno CCL Office by the POC due date.

Type of visit: Case Management - Deficiencies

On 10/3/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Erick Schuk. The purpose of this visit is to follow up on an incident report that was submitted to the Fresno CCL office. It was reported that on 08/03/2022, a medication error occurred resulting staff administering the same medication to R1 twice. During the course of investigation #24-AS-20220729113420, it was found that R2 had multiple falls in the facility and the facility did not report the incidents to the Fresno CCL office. Deficiencies are being issued in accordance to California Code of Regulations, Title 22, Division 6, on the attached 809D. Exit interview conducted and a Plan of Correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Erik Schuk whose signature on this form confirms receipt of these documentsthe state’s words, verbatim · CDSS document, Oct 3, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 4, 2022

87465(a)(4): (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:(4) The licensee shall assist residents with self-administered medications as needed, this requirement was not met as evidenced by Based on record review, the license did not ensure the requirements for this section were met when staff administered two of the same medication to R1, which poses an immediate health and safety risk to residents/clients in care.the state’s words, verbatim · CDSS document, Oct 3, 2022

Plan of correction: Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for this section are met to the Fresno CCL office by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Oct 31, 2022

87211(a)(1): Each licensee shall furnish...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence, this requirement was not met as evidenced by: Based on record review, the licensee did not ensure the requirements for this section were met when LPA observed that R1 had multiple falls in the facility which were not reported to the Fresno CCL Office.the state’s words, verbatim · CDSS document, Oct 3, 2022

Plan of correction: Licensee agrees to train all staff on the requirements of section 87211 and submit proof of attendance and training topics to the Fresno CCL office by the POC due date.

Allegation investigated: Resident's room has a foul odor. Resident's closet is cluttered with soiled linens. Resident's bathroom is unkempt Resident was left unattended. Resident's bathroom is dirty. Staff did not transport resident to medical appointment in a timely manner. Unqualified staff providing transportation for resident's. Facility not properly managing resident's medications. Facility did not seek medical care for resident.

On 08/08/2022, Licensing Program Analyst (LPA) arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator Erik Schuk. Today’s visit included staff interviews. During the investigation, LPA reviewed resident records, interviewed staff and residents, and conducted a facility tour. During the facility tour LPA observed residents’ apartments to be clean with no obstructions to pathways. LPA observed residents’ bathrooms and showers to be clean. Interviews with residents revealed that housekeeping staff will clean resident rooms. CONTINUED TO 9099C Unsubstantiated Interviews with transportation staff revealed that the facility does not transport residents who require assistance with a wheelchair or are unable to transfer in and out of the vehicle. Transportation staff will make arrangements with Comfort Med Trans to transport wheelchair bound residents. Interviews with staff revealed that antibiotic medications are documented on a paper MAR. Antibiotics are administered to residents as prescribed. Based on observation, record review, and interviews the allegations: Resident's room has a foul odor, Resident's closet is cluttered with soiled linens, Resident's bathroom is unkempt, Resident was left unattended, Resident's bathroom is dirty, Staff did not transport resident to medical appointment in a timely manner, Unqualified staff providing transportation for resident's, Facility not properly managing resident's medications and Facility did not seek medical care for resident are found to be UNSUBSTANTAITED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies issued during the inspection. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Erik Schuk, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Aug 8, 2022 · control 24-AS-20220513170250

Type of visit: Required - 1 Year

On 07/28/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Erik Schuk. Facility has one central entry and exit and has implemented a sign in policy/symptom screening for visitors. Facility tour conducted. Facility did not have obstructions blocking pathways, entrances, and exits. No fire clearance issues observed during this inspection. Staff observed to be wearing facial coverings. Residents encouraged to wear facial coverings in common areas and when out of the facility. High traffic areas are sanitized at least once a day. LPA observed signs promoting cough sneeze etiquette, hand-washing, and social distancing. LPA observed hand-sanitizer dispensers at the front entrance and elevator. LPA observed hand-washing signs in facility bathrooms. LPA toured the following resident rooms: 105, 112, 117, 120, 134, 224, A3, B4, B8, E1, E8, and F8. Bedrooms at this facility are single occupant. In room 134, LPA observed medications and knives to be accessible in the apartment. LPA observed a 30 day supply of medications. LPA observed a supply of PPE and cleaning supplies. Staff records reviewed for good health. Residents files observed to have updated emergency contact information. LPA is requesting the following documents be submitted to the Fresno CCL office by 08/11/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A) and Surety Bond CONTINUED TO 809C Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, on the attached 809D. An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Erik Schuk, whose signature on this form confirm receipt of this document.the state’s words, verbatim · CDSS document, Jul 28, 2022

Allegation investigated: Staff fraudulently signed facility MAR stating resident's medications were administered Staff mismanaged resident medications Staff do not respond to resident's call for assistance in a timely manner

On 05/09/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. The allegations: Staff do not respond to resident's call for assistance in a timely manner and Staff mismanaged resident medications were previously cited and the facility recently implemeted a Plan of Correction. Interviews and record reviews revealed that while administering morning medications to residents, S1 would pour all medications and sign off on the MAR that medications were given prior to administering the medications to the residents. S2 observed medications that "were poured but not given"; however, the MAR indicated that medications were administered. CONTINUED 9099C Substantiated Based on observation and interviews, the preponderance of evidence standard has been met, therefore the allegation: Staff fraudulently signed facility MAR stating resident's medications were administered is found to be SUBSTANTIATED A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6, see attached 9099D. An exit interview was conducted, and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Pamela Hamilton, whose signature on this form confirms receipt of this documentthe state’s words, verbatim · CDSS document, May 9, 2022 · control 24-AS-20220408171548

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: May 10, 2022

87207 False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based on interviews and record review, S1 made false/misleading statements when S1 initialed that medications were administered to residents when S1 did not administer medications. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 9, 2022

Plan of correction: Licensee agrees to submit a written statement detialing how the facility will ensure that employees do not make or disseminate any false or misleading statements regarding the facility or services to the Fresno CCL office by the POC due date.

Type of visit: Case Management - Incident

On 05/02/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Case Management - Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Pamela Hamilton. The purpose of today's inspection is to follow up on an incident that occurred on 04/18/2022. It was reported that at the beginning of S2's shift, S2 observed a Medication cup with morning medications poured for R1, but the medications were not administered. S1 was did not administer morning medications, however: S1 documented that medications were given to R1. A deficiency is being issued in accordance with the California Code Regulations, Title 22, Division 6 on the attached 809D. An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Pamela Hamilton, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 2, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 3, 2022

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirementw as not met as evidenced by: Based on record review and interviews, the Licesnee did not ensure all residents were assisted with self-administered medications as needed. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 2, 2022

Plan of correction: Per Licensee, S1 received additional medication training which included shadowing. Documenation of training and training topics was submitted to the Fresno CCL office. POC Cleared during visit.

Allegation investigated: Staff failed to provide a comfortable environment for residents Facility is in disrepair Facility is unkempt

On 04/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Pamela Hamilton. During the investigation, LPA interviewed residents and staff, conducted a facility tour and reviewed records. Based on observation, record review and interviews conducted with residents and staff, the allegations: Staff failed to provide a comfortable environment for residents, Facility is in disrepair and Facility is unkempt 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. No deficiencies issued during this inspection. An exit interview was conducted with Administrator. A copy of this report was discussed and provided to Administrator, Pamela Hamilton, whose signature on this form confirms receipt of this document. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 13, 2022 · control 24-AS-20220304101758

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: Multiple resident(s) sustained pressure injury(ies). Staff left resident in soiled diaper/clothing for an extended period of time Staff does not provide adequate food service for residents.

On 04/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Pamela Hamilton. During the investigation, LPA interviewed residents and staff, conducted a facility tour and reviewed records. Based on observation, record review and interviews conducted with residents and staff, the allegations: Multiple resident(s) sustained pressure injury(ies), Staff left resident in soiled diaper/clothing for an extended period of time, Staff does not provide adequate food service for residents 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. No deficiencies issued during this inspection. An exit interview was conducted with Administrator. A copy of this report was discussed and provided to Administrator, Pamela Hamilton, whose signature on this form confirms receipt of this document. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 13, 2022 · control 24-AS-20220208101724

Allegation investigated: Staff do not respond timely to resident call due to insufficient staffing

On 04/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Pamela Hamilton. During the investigation, LPA interviewed residents and staff, conducted a facility tour and reviewed records. Interviews with residents revealed that facility staff are “slow at coming” when responding to emergency call buttons. During the investigation, LPA observed staff responding to an emergency call 27 minutes after the emergency pendent was pressed. CONTINUED TO LIC9099C Substantiated Based on observation and interviews, the preponderance of evidence standard has been met, therefore the allegation: Staff do not respond timely to resident call due to insufficient staffing is found to be SUBSTANTIATED A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6, see attached 9099D. An exit interview was conducted, and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Pamela Hamilton, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Apr 13, 2022 · control 24-AS-20220203130953

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: May 13, 2022

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following… (3) Skill and knowledge required to provide necessary resident care and supervision… This requirement was not met as evidenced by: Based on observation and interviews, the licensee did not ensure the above requirement was met as evidenced by facility staff not responding to residents timely. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 13, 2022

Plan of correction: Licensee agrees to submit a written statement detailing the facilities plan to train staff on responding to the residents’ emergency call button timely to the Fresno CCL office by the POC due date.

Allegation investigated: Staff did not safeguard resident's personal belongings Resident's room is dirty Staff did not provided resident with adequate bedding Staff did not meet resident's hygiene needs Resident's bathroom has no hand soap Resident's TV is in disrepair

On 04/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Pamela Hamilton. During the investigation, LPA interviewed residents and staff, conducted a facility tour and reviewed records. Consistent interviews with staff revealed that R1 would frequently remove R1’s hearing aid due to the hearing aid making a “whistling” noise in R1’s ear. While R1 resided at the facility, staff found R1’s hearing aid in various places including R1’s dining plate, R1’s sock and R1’s shoe. CONTINUED TO LIC9099C Unsubstantiated LPA was unable to tour R1’s apartment due to R1 no longer being in the facility. LPA viewed apartments belonging to other residents in the facility and did not observe the apartment rooms to be dirty, LPA observed hand soap, and resident TV’s to be in working order. Interviews with staff revealed that staff were trained on how to meet R1’s hygiene needs, however, R1 would refuse. Interviews with the Administrator revealed that resident families provide resident bedding and hand soap. Staff interviews revealed that staff will contact residents’ families when a resident is low on a specific item. Interviews with staff also revealed that soiled bedding is immediately washed, and some residents are provided with one set of bedding. The facility does have “loaner bedding” for a resident if it is needed. Based on observation and record review, the allegations: Staff did not safeguard resident's personal belongings, Resident's room is dirty, Staff did not provided resident with adequate bedding, Staff did not meet resident's hygiene needs, Resident's bathroom has no hand soap, and Resident's TV is in disrepair are UNSUBSTABTIATED. 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. No deficiencies issued during this inspection. An exit interview was conducted with Administrator. A copy of this report was provided to Administrator, Pamela Hamilton, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Apr 13, 2022 · control 24-AS-20220111085127

Allegation investigated: Residents showering needs are not being met

On 04/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Pamela Hamilton. During the investigation, LPA interviewed residents and staff, conducted a facility tour and reviewed records. Consistent statements from staff revealed that once a resident is given a shower, the attending staff will sign off on the shower schedule indicating that the resident was showered. Staff interviews revealed that “some residents will get a shower and others won’t”. LPA reviewed shower records at the above facility and observed the shower schedule was not updated and multiple rooms did not have a staff initial indicating the shower was completed. Substantiated Based on interviews conducted with staff and records review, the preponderance of evidence standard has been met, therefore the allegation: Residents showering needs are not being met is found to be SUBSTANTIATED. A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6, see attached 9099D. An exit interview was conducted, and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Pamela Hamilton, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Apr 13, 2022 · control 24-AS-20211130111055

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: May 13, 2022

(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications… This requirement was not met as evidenced by: Based on interviews conducted and record review, the facility did not ensure residents were assisted with activities of daily living such as bathing as evidenced by facility shower logs and consistent staff statements. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 13, 2022

Plan of correction: Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements of Basic Services are met to the Fresno CCL office by the POC due date.

Type of visit: Case Management - Other

On 04/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Case Management- Deficiencies Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Pamela Hamilton. The purpose of this visit is to follow up on 6 incident reports that were not submitted to the Fresno CCL office with 7 days of occurrence. An incident that occurred on 01/22/2022 was reported on 02/02/2022. Incidents that occurred on the following dates were reported on 03/02/2022: 2/22/2022, 02/21/2022, 02/19/2022, 02/14/2022, and 02/18/2022. Based on record review, a deficiency is being cited in accordance to California Code of Regulations, Title 22, see attached 809D. Exit interview conducted and Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were reviewed and provided to Administrator, Pamela Hamilton, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Apr 13, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 13, 2022

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence… This requirement was not met as evidenced by: Based on record review, the licensee did not furnish a written incident reports within seven days of occurrence as evidenced by the 6 incident reports that were submitted after the 7-day time frame.the state’s words, verbatim · CDSS document, Apr 13, 2022

Plan of correction: Licensee agrees to submit a written statement detailing steps the facility will take to ensure that the requirements of section 87211 Reporting Requirements are met to the Fresno CCL office by the POC due date.

Allegation investigated: Facility neglect resulting in resident developing infection. Facility staff did not observe change in resident's health condition. Resident's bathing needs were not met while in care.

This is an amended report. On 03/09/2022, Licensing Program Analyst (LPA) Walton arrived unannounced at the above facility to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Pam Hamilton. Based on interviews conducted and records reviewed, the allegations: Facility neglect resulting in resident developing infection, Facility staff did not observe change in resident's health condition and Resident's bathing needs were not met while in care are UNSUBSTANTIATED. CONTINUED TO LIC9099C Unsubstantiated This is an amended report 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 deficiencies issued during this inspection. An exit interview was conducted with Administrator. A copy of this report will be provided via email due to COVID-19 precautionary measures. Facility Representative signature on file.the state’s words, verbatim · CDSS document, Mar 9, 2022 · control 24-AS-20211129152314

Type of visit: Office

An informal meeting was held on 02/24/2022 at the Fresno Regional Office. The purpose of the office meeting was to discuss recently identified issues associated with the operation of the facility. The informal conference process was explained during the meeting. The following were in attendance: Diane Navarro, Regional Director of Operations (RDO) Pamela Hamitlon, Executive Director (ED) Melinda Hoffmann, Licensing Program Manager Sergiy Pidgirny, Licensing Program Manger Alexandria Walton, Licensing Program Analyst During this meeting the following issues discussed: Recent deficiencies Staffing concerns The Department offered to submit a referral to the Technical Support Program (TSP), as they may be able to assist in bringing the facility back to substantial compliance. The offer to submit a referral was accepted by the RDO and ED. At the conclusion of this meeting, the Department will submit a referral to TSP.the state’s words, verbatim · CDSS document, Feb 24, 2022

Allegation investigated: Staff are not wearing masks

On 11/03/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct a subsequent complaint investigation at the above faciltiy. LPA introduced self, stated the purpose of the visit and requested to meet with the Executive Director (ED). LPA met with ED, Pamela Hamilton and Resident Service Director (RSD), Olaf Becker. During today's visit, LPA conducted a facility tour with ED and RSD. During the facility tour, LPA observed DS1 to be wearing a facial covering improperly. DS2 and DS3 were observed to not be wearing facial coverings. Front desk staff and care providers were observed to be wearing facial coverings during this inspection. Based on observation, the facility failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care... CONTINUED TO LIC9099C Substantiated in that 3 out 4 dining room staff were observed to be not wearing facial coverings and wearing facial coverings improperly in violation of official government orders requiring the wearing of face coverings while working under specified conditions. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1. An exit interview was conducted and a Plan of Correction was reviewed and developed with Executive Director. A copy of this report and Appeal Rights were provided via email and an electronic read receipt confirms receiving these documents. Facility Representative signature on file.the state’s words, verbatim · CDSS document, Nov 3, 2021 · control 24-AS-20210820151154

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 3, 2021

87468.1 Personal Rights of Residents in All Facilities (a)(2): Residents... shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observation, the facility did not ensure staff are wearing facial coverings as mandated when it was observed that 3 out of 4 dining staff were not wearing facial coverings during the lunch period. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Licensee will submit a plan detailing steps the facility will take to ensure staff wear face masks while in the facility as mandated, by 12/03/2021.

Allegation investigated: Resident sustained an unwitnessed fall resulting in fracture.

ON 07/14/2021, Licensing Program Analyst (LPA) arrived unannounced to conduct a subsequent complaint inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Pamela Hamilton. During this visit, LPA conducted staff interviews. Based on record review and interviews, the above allegation is found to be UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Nothe state’s words, verbatim · CDSS document, Jul 14, 2021 · control 24-AS-20210308092805