Simply Caring Angels

Type of visit: Required - 1 Year

Licensing Program Analyst's (LPA)'s LPA Shawna Doucette and LPA Miriam Flores arrived at the facility unannounced to conduct an annual inspection. LPA's was granted entry by Staff, Cipriana Dela Cruz. LPA explained the purpose of the visit and Administrator Ana Liza Aratea responded to the facility to meet LPA's to conduct the visit. A tour of the facility was conducted with the Administrator. The residence was set at 78 F temperature and free of passageway obstructions inside and outside. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication cabinet in the kitchen. Cleaning supplies were unlocked in a cabinet above the washing machine. Smoke detectors and carbon monoxide detectors were checked and properly working. Fire extinguishers were charged and had service dates of 05/22/23. LPA checked water temperature which measured at 110.6 F. There was outdoor seating for the residents. Resident, medication and staff records were reviewed. LPA observed a medication error for R1. R1 medication count did not match start date on centrally stored log. Facility staff did not have hospice or home health training. Facility did not have home health care plans or hospice care plans for all residents. Current first aid and CPR were reviewed. LPA took photos of medications and unlocked cleaning supply cabinet. Refer to 809d for deficiencies A copy of this report with plan of correction and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 24, 2023

Type of visit: Case Management - Other

On 12/05/22, Licensing Program Analysts (LPAs) M. Medina and L. Salazar arrived to conduct an unannounced Case Management visit to follow up on three Hospice exception requests submitted by Licensee to the Department. On 10/26/22, the Department requested licensee to provide hospice care plans for each resident that a Hospice exception was made for. LPAs toured the facility and observed residents in care. LPAs met with licensee who stated there is one out of six residents in care that are currently receiving Hospice care. Licensee does not have care plan available to provide to LPA. Resident (R1) is currently receiving home health services for a prohibited condition. An exception request for the prohibited condition has not been submitted by licensee to retain this resident and prohibited condition has not been reviewed or approved by the Department. The following deficiency is being cited on the attached 809-D, if not corrected, poses an immediate risk to the health and safety to resident's in care. Exit interview conducted. A copy of this report provided to Licensee for facility records.the state’s words, verbatim · CDSS document, Dec 5, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Dec 6, 2022

Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly. (1)Stage 3 and 4 pressure injuries. **This was not met as evidenced by R1 has a Stage 3 pressure injury being treated by Home Health.the state’s words, verbatim · CDSS document, Dec 5, 2022

Plan of correction: Licensee will submit an exception request to the Department for the prohibited condition that the licensee requests to retain. A care plan will be submitted with the expeption request by the Plan of Correction date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87608(5)(A) · Plan of correction due date: Dec 6, 2022

5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(A) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. **This was not met as evidenced by R1 has full bed rails and not on hospicethe state’s words, verbatim · CDSS document, Dec 5, 2022

Plan of correction: Licensee will submit hospice exception request which includes a hospice care plan to Department for R1 by POC due date.

Type of visit: Required - 1 Year

On 10/24/22, Licensing Program Analysts (LPAs) L. Salazar and M. Medina arrived at the facility unannounced to conduct a annual infection control inspection. LPAs were greeted by Licensee, stated the purpose of the visit and were allowed entry into the facility. COVID precautionary measures were taken at the time of entry. LPA entered through the central entry point where hand sanitizer and visitor policy was posted. LPAs observed the Staff and Visitor sign in and Covid Symptom Screening area. Facility Mitigation plan has been submitted to CCL. Infection control procedures described in the plan which were observed and reviewed by LPA include: Daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, emergency staffing plan, PPE storage, use and training, as well as daily infection control procedures. Licensee is identified as the Infection Control Lead for the facility. LPA toured the facility inside and out. Postings to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Staff were all observed wearing face coverings. Facility has multiple designated visitation areas available. LPA observed 30-day medication supply and PPE accessible to staff. Common and resident bathroom sinks are stocked with liquid soap and paper towels for hand washing. Through LPA’s observations, documentation review and interview with Licensee, the required infection control practices are found to be in compliance. No deficiencies cited on todays visit.the state’s words, verbatim · CDSS document, Oct 24, 2022

Type of visit: Case Management - Deficiencies

On 10/24/2022, Licensing Program Analysts (LPAs) M. Medina and L.Salazar conducted a Case Management visit observed during Annual Required Infection Control inspection. During the course of Inspection is was observed that 5 of 6 residents had full bed rails and not receiving hospice services. R5 has a prohibited condition being treated by Home Health. Deficiencies cited on the attached 809-D. Based on today's visit, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, Chapter on the attached 809D. A Civil Penalty is being assessed in the amount of $500. Exit interview conducted. Appeal rights provided. A copy of this report was provided for facility records.the state’s words, verbatim · CDSS document, Oct 24, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(5)(A) · Plan of correction due date: Oct 25, 2022

5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(A) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. **This was not met as evidenced by 5 of 6 residents have full bed rails and not on hospicethe state’s words, verbatim · CDSS document, Oct 24, 2022

Plan of correction: Licensee will submit hospice exception request to Department for R4 & R5. Licensee will remove bed rails for R2 & R6 and request a Dr orders for half bed rails for R3. All corrections to be completed by POC due date **Immediate Civil Penalty Assessed

From the deficiency page — Deficiency type: Type A · Section cited: CCR87615(a)(1) · Plan of correction due date: Oct 25, 2022

Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly. (1)Stage 3 and 4 pressure injuries. **This was not met as evidenced by R5 has a Stage 3 pressure injury being treated by Home Health.the state’s words, verbatim · CDSS document, Oct 24, 2022

Plan of correction: Licensee will submit hospice exception request to Department for R5 by POC due date.

Type of visit: Case Management - Health Checks

On 12/9/21, Licensing Program Analysts (LPAs) K. Kaur and S. Doucette arrived at the facility unannounced to conduct a Health & Safety inspection to review newly admitted resident records. LPA's reviewed resident file, which did not have a LIC602 Physicians Report. LPA's reviewed residents medications and records which did not show medications were given to R1 for 12/9/21. LPAs obtained original License that had previous permissions from Licensee. The most current License was posted in the facility. LPA's toured the facility and checked on residents in care. During the tour of the facility, LPA observed the stove knobs to be on the stove and accessible to residents in care. Facility has a two day supply of perishable food and a 7 day supply of nonperishable foods. Based on interviews conducted, tour of facility and records review, deficiencies are being issued in the areas evaluated and listed on the 809-D according to California Code of Regulations Title 22, Division 6 and Health and Safety Code. An exit interview was conducted and Plan of Correction was reviewed and developed with the Licensee. Licensee was provided with a copy of this report and Appeal Rights via email.the state’s words, verbatim · CDSS document, Dec 9, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Dec 31, 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: Based on records review and observation Licensee did not administer R1's medications for 12/9/21 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Plan of Correction POC Licensee agrees to provide staff training on administering and logging medications. Licensee will submit agenda and signed sheet by staff by POC due date 12/31/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(d) · Plan of correction due date: Dec 10, 2021

87705 Care of Persons with Dementia (d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia. This requirement was not met as evidenced by: Based on observation Licensee did not have the stove knobs locked which were accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Plan of Correction POC Licensee removed stove knobs and locked them making the knobs inaccessible to residents in care. POC was corrected during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Dec 31, 2021

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's This requirement was not met as evidenced by: Based on records review and observation R1 did not have a completed LIC 602 Physicians Report or TB test in the residents file which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Plan of Correction POC Licensee agrees to submit R1's physicians report and a written understanding of the regulation by POC due date.

Type of visit: Case Management - Other

On 10/27/21, Licensing Program Analyst (LPA) L. Salazar conducted an annual continuation visit. LPA was greeted by licensee and was allowed entry. COVID precautionary measures were taken prior to LPAs entry into facility. LPA toured the facility and observed 6 out 6 residents in care. Three non-ambulatory residents in care were sitting in recliners in the living room, watching TV and three residents were sleeping in their individual rooms when LPA arrived. LPA provided the following Technical Resource guides for the facility: Hospice Care Pressure Injuries Medication Management LPA provided licensee with an updated license, changing the Hospice Waiver from six (6) to a Hospice Waiver of one (1). LPA obtained the initial license that was issued and replaced license with updated license. No deficiencies cited on todays visit.the state’s words, verbatim · CDSS document, Oct 27, 2021

Type of visit: Office

An Informal Office Meeting/ Conference call was held on 08/26/2021 at the Fresno Regional Office. The informal conference process was explained during this meeting. The following were in attendance: ANA LIZA ARATEA, Licensee, BRENDA WHITE, Regional Manager, MELINDA HOFFMANN, Licensing Program Manager I, LISA SALAZAR, Licensing Program Analyst SHAWNA DOUCETTE, Licensing Program Analyst The purpose of the informal meeting/conference meeting was to discuss recent deficiencies and the necessity of bringing the facility back into compliance. Additionally, the following was discussed: Site inspections will increase to monitor compliance; Necessity of submitting Incident and Death reports via fax or USPS mail; Request to submit updated LIC 9020 for each new resident on monthly basis; Hospice Waiver will be decreased from 6 to 1; Eviction Procedures/Regulations were provided to licensee regarding R1.the state’s words, verbatim · CDSS document, Aug 26, 2021

Type of visit: Case Management - Deficiencies

On 8/11/2021, Licensing Program Analyst (LPA)s Shawna Doucette and LIsa Salazar contacted Licensee Ana Liza P Aratea to conduct a Case Management visit. LPAs knocked on the door and there was no answer. Licensee responded to the facility about 15 minutes later. Licensee Ana Liza P Aratea allowed LPA's into the facility. The purpose of today's visit was to check care and supervision. LPA's obtained information that there were no staff in the facility at night. Licensee gave a false name of staff on duty and provided another staffs record for the staff on duty. Staff on duty was not fingerprint cleared. Based on interviews conducted, tour of facility and records review, deficiencies and Civil Penalty are being issued in the areas evaluated and listed on the 809-D according to California Code of Regulations Title 22, Division 6 and Health and Safety Code. An exit interview was conducted and Plan of Correction was reviewed and developed with the Licensee. Licensee was provided with a copy of this report and Appeal Rights.the state’s words, verbatim · CDSS document, Aug 11, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.17(b)(1)(A) · Plan of correction due date: Aug 12, 2021

Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances(b) In addition to the applicant, the provisions of this section shall apply to criminal record clearances and exemptions for the following persons: (1)(A) Adults responsible for administration or direct supervision of staff. This requirement was not met as evidenced by: Based on observation, interviews and record review staff 1 (S1) was not fingerprinted while caring for residents in the facility, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: Plan of Correction POC Staff was immediately removed from the facility at the time of visit. Civil Penalty was issued.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(1) · Plan of correction due date: Aug 12, 2021

Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidenced by: Based interview, record review and observation Licensee did not hire qualified staff (not fingerprinted, no evidence of training or staff records), which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: Plan of Correction POC Licensee agrees to submit a statement of the understanding of this regulation by POC due date 8/26/21

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Aug 11, 2021

Personal Accommodations and Services apply:(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on obervation on 6/2/21 Licensee did not keep passageways clear of obstruction in the enclosed covered patio located off of the family room and master bedroom which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: Plan of Correction POC Licensee cleaned room and cleared passageways.POC cleared at visit.

Type of visit: Case Management - Deficiencies

On 08/11/21, Licensing Program Analysts (LPAs) L.Salazar and S. Doucette arrived at the facility unannounced to conduct a Health & Safety inspection to verify care and supervision. LPAs obtained information there was no staff in the facility at night. LPAs rang the doorbell, no one answered. LPAs called the facility phone which went straight to a fax machine. Licensee arrived at the facility shortly after. LPAs toured the facility and checked on residents in care. LPA Salazar requested to see staff files and resident files. LPAs observed Resident R1, who is bedridden and not receiving Hospice or Home Health care. R1 is in need of 24 hour nursing care. LPAs attempted to interview staff on site and were unsuccessful due to licensees interference and refusal to allow LPAs to interview staff. LPA Salazar reviewed facility Hospice Initiation requests for Residents R5, R6, and R7. Residents passed away in 2020 and 2021. No Death Reports were submitted. Based on number of deficiencies, reduction of Hospice Waiver is under review. Informal Meeting with licensee has been scheduled for 08/26/21. Based on interviews conducted, tour of facility and records review, deficiencies and Civil Penalty are being issued in the areas evaluated and listed on the 809-D according to California Code of Regulations Title 22, Division 6 and Health and Safety Code. An exit interview was conducted and Plan of Correction was reviewed and developed with the Licensee. Licensee was provided with a copy of this report and Appeal Rights.the state’s words, verbatim · CDSS document, Aug 11, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87455(c)(2) · Plan of correction due date: Aug 11, 2021

(c) No resident shall be accepted or retained if any of the following apply:(2) The resident requires 24-hour, skilled nursing or intermediate care as specified in Health and Safety Code Sections 1569.72(a) and (a)(1). This requirement was not met as evidenced by LPAs observation of Resident R1. R1 requires 24 hour skilled nursing care. Hospice care was terminated as of 06/24/21. No evidence of any other services being provided.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: ***Informal meeting scheduled to discuss deficiencies.***

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Aug 11, 2021

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 licensee giving a false name and employee file of an employee who was not fingerprint cleared or listed on the facility roster.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: ***Informal meeting scheduled to discuss deficiencies.***

From the deficiency page — Deficiency type: Type A · Section cited: CCR87755(b) · Plan of correction due date: Aug 11, 2021

The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility. This requirement was not met as evidenced by LPA Doucette's observation of LPA Salazar's efforts to speak to Staff S1 and Staff S2 privately. Licensee would not leave the area and was responding to LPA's questions to S1 & S2.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: ***Informal meeting scheduled to discuss deficiencies.***

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Aug 13, 2021

Reporting Requirments: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.other death reports were not submitted.This requirement was not met as evidenced by Resident R5's Death Report LIC624a being received 11days after the death. No Death Report was received for Resident R6,R7, R5.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: L1 will submit LIC624/LIC624a for R6 & R7 by POC date. ***Informal meeting scheduled to discuss deficiencies.*** Civil Penalty Assessed - Repeat Violation

Type of visit: Required - 1 Year

Licensing Program Analyst LPA Shawna Doucette and LPA Lisa Salazar conducted an Annual Inspection on this date. LPAs were met by Licensee Ana Liza Aratea and discussed the purpose of the visit. LPAs and Licensee Ana Liza Aratea began the tour at the front entrance/office of the facility. Licensee does not have a mitigation plan in place. LPA Lisa Salazar emailed Licensee the LIC 808. Visitor log-in and disinfection station was observed upon entry. There was no thermometer at entrance and temperatures were not checked when LPAs entered the facility. Licensee was not wearing a mask in the facility. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas. LPA observed a two day supply of perishable food and seven day supply of non-perishable food. LPA observed the following personal protective equipment in facility; masks and gloves. Licensee stated PPE is kept off site. Staff records were reviewed for infection control training. Licensee did not have infection control training for staff. LPA observed all facility staff wearing masks. Resident’s files were not updated for emergency contact information. Exit interview was conducted and a copy of this report was providedthe state’s words, verbatim · CDSS document, Aug 5, 2021

Type of visit: Required - 1 Year

On 08/05/2021, at 12:30pm, Licensing Program Analysts (LPAs) L. Salazar and LPA S. Doucette conducted an unannounced Annual Required Inspection and met with Licensee, Ana Liza Aratea. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. 5 residents and 2 staff were present in the facility during the inspection. The facility is a 6 bedroom, 3 1/2 bathroom house. Licensee accompanied LPA inside and out of the facility during this inspection. LPA inspected the kitchen area and observed a two-day supply of perishable and a seven day supply of non-perishable food. Knives and toxics were kept in an unlocked kitchen cabinet under the sink. At 12:30pm, LPA tested one carbon monoxide detector and one smoke detector located in the hallway area. Both devices were functional. Deficiencies are being cited based on LPAs observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see 809 D. An exit interview was conducted and Plans of correction were reviewed and developed with the licensee. A copy of this report and appeal rights were discussed and left with licensee.the state’s words, verbatim · CDSS document, Aug 5, 2021

The state marks this report as 9 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility accepted a resident without an admission agreement

On 06/02/2021, Licensing Program Analysts (LPA) L. Salazar and S. Doucette arrived to the facility unannounced to conduct the required 10 day inspection. LPAs conducted interviews with the reporting party and licensee. LPA requested to see the following documentation: 1.) Admission Agreement for Residents in care 2.) Pre-Admission Appraisal for residents in care During the course of the investigation, LPAs toured the facility, conducted interviews and reviewed resident files for records maintained at the facility. Based on interviews and observation of record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, see LIC 9099D. Exit interview conducted and appeal rights given. Substantiatedthe state’s words, verbatim · CDSS document, Jun 2, 2021 · control 24-AS-20210525160626

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(17)(A) · Plan of correction due date: Jun 4, 2021

Admission Agreement (b) Each resident’s record shall contain at least the following information:(17) Documents and information required by the following:(A) Section 87457, Pre-Admission Appraisal; This requirement was not met as evidenced by LPA's review of all residents records. No pre-appraisal has been completed or maintained in the resident files.the state’s words, verbatim · CDSS document, Jun 2, 2021

Plan of correction: Licensee will review, sign and date and the Title 22 regulation being cited. Licensee will ensure all admission agreements are prepared and filled out in their entirety before accepting a new resident.