Magnolia Place

Allegation investigated: Staff hit residents arm Staff forcibly pulled a residents hair Staff speak inappropriately to residents in care

On 08/17/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver complaint findings on the above allegations. LPA introduced self, stated the purpose of the visit, and met with Director of Residential Services Shellie Whitlock and Administrator Paul Anderson. During the course of the investigation record were reviewed and interviews were conducted. S1 had hit R1 and R2’s arm to get the residents’ attention. S1 spoke inappropriately to R1 and R3 when assisting the residents. S1 had pulled R2’s hair when R2 was trying to get out of the commonly used bathroom. Based on record reviewed and interviews conducted, the preponderance of evidence standard has been met,therefore, the above allegations are found to be SUBSTANTIATED. Under California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and appeal rights was provided to Administrator, whose signature confirm receipt of this report. Substantiatedthe state’s words, verbatim · CDSS document, Aug 17, 2023 · control 24-AS-20230705155208

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Aug 18, 2023

87468.1 Personal Rights of Residents in All Facilities(a)(1) Residents in all residential care facilities for the elderly shall…be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:the state’s words, verbatim · CDSS document, Aug 17, 2023

Plan of correction: Facility conducted an internal investigation and Administrator stated S1 have been terminated on 07/13/23 and all staff in-service training on Abuse was completed on 07/06/23, 07/07/23, 07/10/23, and on 07/20/23. Copies of S1 termination, all staff in-service training, and staff attendance for in-service training was received. POC cleared during visit.

Type of visit: Case Management - Incident

On 07/11/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a case management visit. LPA met with Director of Residential Services (DRS) Shellie Whitlock and announced the purpose of the visit. Administrator Paul Anderson arrived shortly. LPA discuss the Soc 341 that was received by the department on 07/07/23. Administrator was informed by Staff 1 (S1) and Staff 2 (S2) that staff have witnessed Staff 3 (S3) slapping one resident’s wrist, slapping another resident on the back of and pulling another resident’s hair. On 07/10/23, Administrator follow-up to department of incident resulted in the termination of employment of S3. Interview was conducted with DRS who stated internal investigation was completed by 07/08/23 and S3 no longer employed effective 07/08/23. However, the Soc 341 reported received was in relation to the same allegations in complaint 24-AS-20230705155208 received by the department. The information provide will be reviewed; a follow up case management will be conducted if necessary. An exit interview was conduct. A copy of this report was provided to Administrator, whose signature on this report confirms receipt of report.the state’s words, verbatim · CDSS document, Jul 11, 2023

Allegation investigated: Facility staff failed to seek timely medical attention for resident fall. Facility staff mismanaged residents medications.

On 04/28/23, Licensing Program Analyst (LPA), M. Yang, arrived at the facility unannounced to deliver complaint findings for the above allegations. LPA met with Administrator Paul Anderson and Director of Residential Services Shellie Whitlock and discussed the purpose of the visit. The Department conducted interviews with staff and reviewed records. Based on interviews conducted facility staff failed to seek medical attention in a timely manner after a resident’s unwitnessed fall that resulted in the resident sustaining a pelvic fracture. An Immediate Civil Penalty is being assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. During the course of the investigation, records were reviewed, and interviews were conducted with staff. Based on interviews conducted staff had administered a medication that was not prescribed to the resident 1(R1). Substantiated Based on the interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. See attached LIC 9099D form for deficiencies cited in accordance with Title 22 California Code of Regulations. An exit Interview conducted. A copy of this report and Appeal Rights was provided to Administrator, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Apr 28, 2023 · control 24-AS-20230123092901

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87411(a) · Plan of correction due date: May 11, 2023

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required… The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidence by: Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above when Resident 1 a non-verbal and paralyzed resident had an unwitnessed fall on 12/14/23 and was not sent to the hospital until 12/16/23 which poses/posed an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 28, 2023

Plan of correction: Facility has agreed to provide an all care staff in-service training to review all aspects of care and supervision. A review of when to call for Emergency Medical Services will also be conducted by due date. Administrator will submit staff attendance rooster which will include include date, signature of facility staff who attended and as well as a copy of training materials to CCLD via email by 05/11/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5)(A) · Plan of correction due date: May 1, 2023

87465(a)(5)(A) Incidental Medical and Dental Care Facility staff…shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered… (A) Medications…prescribed for self-administration which have been authorized by the person's physician. This requirement was not met as evidence by: Based on record reviewed and interviews conducted, the licensee did not comply with the section cited above when staff administered Norco to resident 1(R1). Medication was not prescribed by the resident’s physician which poses/posed an immediate health, safety, or personal rights risks to the person in care.the state’s words, verbatim · CDSS document, Apr 28, 2023

Plan of correction: Licensee shall have all med tech to be retrained on administering medication. Copies of trainings and rooster of staff attendance which will include signature of staff who attended and date. Trainings and rooster will be submitted to department by 5/11/23. A plan of correction of an action plan the Licensee will take to ensure regulations are met. Action plan shall include double checking medications with MARs before administering medications to resident and ongoing staff trainings on administering medications. POC of action plan will be submitted to department via email by 5/1/23.

Type of visit: Case Management - Annual Continuation

On 04/28/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct a continuation of the Required Annual Inspection. LPA met with Administrator Paul Anderson and Director of Residential Services Shellie Whitlock and stated the purpose of the visit. A sample of the residents’ file reviewed to have update emergency contacts, Admission agreement, and physician report. A sample staff files were also reviewed. Staff files were observed to have current First Aid/CPR, Personal Record, and TB results. No deficiencies issued during this inspection. An exit interview was conducted. The following documents are requested and submitted to Fresno CCL by: 5/05/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, Theft and Los procedure/policy, and current Administrator Certificate. A copy of this report was provided to Licensee, whose signature on this form confirms receipt of these report.the state’s words, verbatim · CDSS document, Apr 28, 2023

Type of visit: Required - 1 Year

On 04/20/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Required Annual Inspection. LPA were greeted by receptionist, stated the purpose of the visit and were allowed entry into the facility. LPA met with Administrator (ADM) Paul Anderson and Director of Residential Services (DRS) Shellie Whitlock. LPA discuss the purpose of the inspection. LPA conducted tour of facility with ADM and DRS. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. LPA toured resident bedrooms in Assisted Living and Memory Care. LPA observed 11 of the 132 rooms in the facility. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Bathrooms hot water temperature was tested range between 109.8 degree F to 110.1 degree F. LPA observed securely fastened grab bars and non-skid mat in all tub/shower areas. Trash bin with lids and hand washing posting was observed. LPA interviewed residents. LPA toured kitchen to the common areas. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. Temperature tested for refrigerator at 40 degree F. and freezer at -1 degree F. Medications were stored in a locked medication room in a medication cart. Medication records and medications were reviewed. First Aid Kit contained the required supplies and stored in the medication room. LPA toured and observed residents in the activity room on the 2nd floor. Fire extinguisher was observed with a service date of: 09/28/22. Last Fire drill completed on 03/27/23. The outside was toured and observed to be free from debris. There was outdoor seating for the residents. LPA will return to review records and finish the inspection tool. An exit interview was conducted with ADM and DRS. A copy of this report was discussed and left with the Administrator Paul Anderson, whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Apr 20, 2023

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 02/06/23, Licensing Program Analyst (LPA) M. Yang conducted an unannounced case management inspection regarding incident report received from facility on 1/25/23. LPA met with Administrator Paul Anderson and Director of Residential Services Shellie Whitlock. The purpose of the today's visit is to follow up on the incident report that was submitted to department on 1/25/23 of incident occurred where medications was not administered. The department conducted interviews and reviewed records shown 30 residents did not receive residents' evening medications on 01/15/23. A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. Exit Interview conducted. A copy of this report and appeal rights was provided via email. Report signed on site.the state’s words, verbatim · CDSS document, Feb 6, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Feb 7, 2023

87465(a)(5) Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not ensure staff administer medications to 31 residents on the evening of 01/17/23 which poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Feb 6, 2023

Plan of correction: Licensee stated all medication technician staffs has been retrained on administering medication on 01/31/23. Copies of trainings and rooster of staff attendance will be submitted to department by 02/07/23. A plan of correction of action plan the Licensee will take shall be submitted to CCL. POC shall include facility MAR to be reviewed by staff and ongoing staff trainings on administering medications. POC of action plan will be submitted to department by 02/07/23.

Allegation investigated: Facility staff failed to meet resident's diabetic needs, resulting in hospitalization's Facility staff restrained resident, resulting in injury Resident is left soiled for extended periods of time Facility staff are not safeguarding resident's property Resident was not afforded dignity

On 01/24/23, Licensing Program Analyst (LPA), L. Salazar arrived at the facility unannounced to conduct the required 10-day site visit. LPA was greeted by receptionist, stated the purpose of the visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry. Facility census is 93 in Assisted Living (AL) and 27 in Memory Care. During the investigation, LPA conducted records review and interviews. Based on the information received, Resident R1 required a level of diabetic care needs that were not being provided, resulting in two hospitalization's. A review of R1's file and physician's report indicates R1 is confused/disoriented & has aggressive/inappropriate behaviors. Records review and interviews reveal that staff would hold R1's hands/arms to avoid being hit, attempting to assist with R1's care needs. LPA's observation of records and pictures show injuries occurred to R1's arms and hands. (Continued on 9099-C) Substantiated (Continued from 9099) Interviews and records review evidence that R1 required care and supervision for incontinence care that was not provided by staff due to resident's refusal and cognitive mental state at the time. R1 was left soiled for several hours, on more than one occasion, while facility waited for assistance from R1's family. Records review and interviews evidence R1 did not have the initial personal property inventory list LIC621 , which is required at the time of admission. R1's walker was missing and a sheet set for R1's bed was also missing. Interviews evidence R1 was sent out to the hospital, with their lower body wrapped in only a sheet. R1 had no under garments on under the sheet, resulting in R1 being naked and possibly exposed. Based on the: LPA’s records review, interviews and observation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D. If not corrected, the violation will have a direct and immediate risk to the health and safety, or personal rights of resident's in care. In accordance with the California Code of Regulations, Title 22. An immediate civil penalty in the amount of $500 is being assessed in the amount of $500. An exit interview was conducted with Administrator. A plan of correction was developed by Administrator and reviewed with LPA. A copy of this report and appeal rights were discussed and provided at the time of visit.the state’s words, verbatim · CDSS document, Jan 24, 2023 · control 24-AS-20220919113811

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.49(c)(1) · Plan of correction due date: Jan 25, 2023

§1569.49 Civil penalties (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations: (1) Any violation that the department determines resulted in the injury or illness of a resident. This requirement was not met as evidenced by LPAs review of hospital and facility records evidencing R1 was not receiving the required blood sugar readings and or insulin injection per the physician's orders, resulting in hospitalization on two occasions. This poses a direct and immediate risk to the health and safety, or personal rights of resident's in care. A civil penalty in the amount of $500 is being assessed. This poses a direct and immediate risk to the health and safety, or personal rights of resident's in care.the state’s words, verbatim · CDSS document, Jan 24, 2023

Plan of correction: Administrator provided LPA with a Diabetic policy/plan covering procedures effective 08/2022. An in-service training was completed with all Memory Care staff on 01/23/23. LPA received signed training attendance logs evidencing the training. **POC Cleared**

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 25, 2023

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by LPAs observation of pictures, records review and interviews. R1's hands/arms were held while staff were attempting to assist in daily living needs. This poses an immediate risk to resident's in care.the state’s words, verbatim · CDSS document, Jan 24, 2023

Plan of correction: Administrator will provide additional dementia training with an emphasis on how staff will handle behaviors including aggressiveness and sun downing.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Feb 10, 2023

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met aas evidenced by LPAs interviews and records review that incontinence care was not provided by staff due to resident's refusal and cognitive mental state at the time. R1 was left soiled for several hours, on more than one occasion, while facility waited for assistance from R1's family.the state’s words, verbatim · CDSS document, Jan 24, 2023

Plan of correction: Administrator will provide incontinence training to all staff with an emphasis on resident's with dementia and behaviors. *POC due date 02/10/2023*

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a) · Plan of correction due date: Feb 3, 2023

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153 (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.the state’s words, verbatim · CDSS document, Jan 24, 2023

Plan of correction: Administrator will create an additional resident reocrds checklist that ensures residents receive all the LIC required documents. Administrator will provide checklist by POC due date of 02/10/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Feb 10, 2023

87468.1 Personal Rights of Residents in All Facilities (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..., This requirement was not met as evidenced by LPA's interviews with staff and reporting party that resident was sent to hospital via EMS with only a sheet (naked) wrapped around their lower body.the state’s words, verbatim · CDSS document, Jan 24, 2023

Plan of correction: Administrator will conduct an all staff in service reviewing the full regulation 87468.1. Administrator will send a sign in sheet evidencing staff have reviewed and understand the regulation. Plan of Correction due 02/10/23.

Type of visit: Case Management - Other

On 09/28/22, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit. LPA was greeted by Executive Director, stated the purpose of the visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry. Assisted Living census is 92 and Memory Care has a census of 27. The purpose of LPA's visit is to deliver Resident R1's file that was obtained on 09/21/22. LPA will return at a later date. No deficiencies cited on today's visit.the state’s words, verbatim · CDSS document, Sep 28, 2022

Allegation investigated: Neglect/ lack of care & supervision resulted in residents engaging in physical altercation causing the resident to sustain fractures

On 8/26/22, Licensing Program Analyst (LPA) M. Medina conducted visit to deliver findings on this complaint. LPA met Paul Anderson, Executive Director and stated purpose of visit. During the course of the investigation, the department conducted interviews and reviewed records. Based on review, on 5/25/22, Resident 1 (R1) and Resident 2 (R2) were in the television room when R1 assaulted R2, resulting in R2 being hospitalized for fractured ribs and pneumothorax requiring a chest tube placement. R1 and R2 had two previous altercations, one of which required R2 to be sent to the hospital. Staff were instructed to supervise residents in the television room however due to insufficient staffing, staff were assisting other residents when the incident occurred. Based on the above information, the preponderance of evidence standard has been met. The allegation that lack of supervision resulted in R2 sustaining a fracture while in care is Substantiated. An immediate civil penalty of $500 is assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any. Substantiatedthe state’s words, verbatim · CDSS document, Aug 26, 2022 · control 24-AS-20220526130257

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 27, 2022

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by staff not supervising residents in the television room, resulting in R1 assaulting R2, requiring R2 to be hospitalized for fractured ribs and pneumothorax requiring chest tube placement. This is an immediate risk to resident health and safety.the state’s words, verbatim · CDSS document, Aug 26, 2022

Plan of correction: Administrator will submit written plan within 24 hours, that details the steps that will be taken to ensure this regulation is met. The plan shall include a date(s) that staff, including lead and supervisory, will be trained on personnel requirements within 10 days of the POC due date (9/12/22). Facility shall submit proof of training to licensing when completed.

Type of visit: Case Management - Deficiencies

On 8/26/2022, Licensing Program Analysts (LPA) M. Medina arrived to conduct a Case Management visit related to concerns reported to Department. The concerns were reported to Department during an unrelated Complaint Investigation. LPA introduced self and stated purpose of visit. LPA met with Francine Reyes, Director of resident services. Facility toured. During the course of complaint investigation conducted it was observed that the air conditioning in room #10 was not working properly and the toilet seat in resident bathroom #1 was missing. Deficiencies cited on the attached 809-D. Exit interview conducted. A copy of this report was provided for facility records. .the state’s words, verbatim · CDSS document, Aug 26, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 26, 2022

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. **This was not met as evidenced by . During the course of a prior complaint investigation conducted it was observed that the air conditioning in room #10 was not working properly and the toilet seat in resident bathroom #1 was missing.the state’s words, verbatim · CDSS document, Aug 26, 2022

Plan of correction: During subsequent facility tour on 8/26/22. LPA observed air conditioning unit in room #10 to have been replaced and working properly. The toilet seat in resident bathroom #1 to be replaced DEFICIENCY CLEARED AT TIME OF CASE MANAGEMENT VISIT.

Type of visit: Case Management - Health Checks

On 08/04/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management - health checks inspections. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Resident Service Director, Francine Reyes. The purpose of today's visit is to follow up on an incident report submitted to the Fresno CCL office regarding a possible fire at the facility. LPA conducted a facility tour and observed residents throughout the facility doing daily activities. No deficiencies issued during today's inspection. Exit interview conducted. A copy of this report was discussed and provided to Resident Service Director, Francine Reyes, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Aug 4, 2022

Type of visit: Required - 1 Year

On 5/27/22 at 1:00PM, Licensing Program Analyst L. Salazar arrived unannounced to conduct an annual infection control inspection. LPA was greeted by Executive Director, stated purpose of visit. 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. LPA 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 were observed and reviewed with 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. The Executive Director 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 well stocked with liquid soap and paper towels for hand washing. Through LPA’s observations, documentation review and interview with Administrator, the required infection control practices are found to be in compliance. No deficiencies cited on today’s inspection.the state’s words, verbatim · CDSS document, May 27, 2022

Type of visit: Case Management - Health Checks

On 05/25/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a Health and Safety visit. LPA was greeted by Executive Director, stated purpose of the visit. COVID precautionary measures were taken at the time of entry. LPA toured the memory care portion of the facility with Executive Director and LVN. LPA observed 28 residents in memory care. LPA observed staffing schedule that showed 4 staff members working on each shift. No deficiencies cited on today's inspection.the state’s words, verbatim · CDSS document, May 26, 2022

Allegation investigated: Visitors were not wearing masks.

On 11/05/21, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required 10 day site inspection. LPA was greeted by Executive Director, stated purpose of visit and was allowed entry into the facility. COVID precautionary measures were taken at the time of LPA's entry. During the course of the investigation, LPA toured the facility inside and out. During the tour, LPA observed all staff members wearing masks. Residents were observed social distancing in the dining area. Based on LPA's observation, there was not an evidence to support this allegation that occurred the year prior. 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 allegations are UNSUBSTANTIATED. Exit Interview conducted. No deficiency issued on today's vist. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 5, 2021 · control 24-AS-20211028110923

Allegation investigated: Facility did not seek appropriate emergency medical care for resident. Facility did not coordinate care with home health services agency.

On 07/22/2021, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to deliver findings on the above allegation. During the course of the investigation, LPA conducted interviews with staff and reporting party. LPA requested documentation from Executive Director evidencing the effort to seek emergency medical treatment due to a change of condition for R1. The facility was unable to provide. LPA conducted review of medical records from hospital and Emergency Medication Services. Records revealed Urgent Care and family of R1 initiated emergency services required. The Department investigated the above allegations. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the allegations above are 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, Jul 22, 2021 · control 24-AS-20201228090245

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.49(c)(1) · Plan of correction due date: Jul 22, 2021

.The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations: (1) Any violation that the department determines resulted in the injury or illness of a resident. This requirement was not met as evidenced by: LPA's observation of hospital medical records. Facility did not seek emergency medical treatment for Resident R1 on 11/20/2020, resulting in hospitalization.the state’s words, verbatim · CDSS document, Jul 22, 2021

Plan of correction: Facility has inserviced all staff on seeking appropriate medical care for residents in the facility. In the case of a change in condition, 911 will be dispatched, Resident's Representative and MD will be notified. ***POC cleared/Civil Penalty Assessed***

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.80(a) · Plan of correction due date: Jul 22, 2021

(a) A resident of a residential care facility for the elderly, or the resident’s representative shall have the right to participate in decisionmaking regarding the care and services to be provided to the resident. Accordingly... the facility shall coordinate a meeting with... the resident’s representative... an appropriate member...of the facility’s staff, if the resident is receiving home health services in the facility...and a representative of the home health agency involved,. The facility shall ensure that participants in the meeting prepare a written record of the care the resident will receive in the facility... This requirement was not met as evidenced by interview with Executive Director stating a meeting with Home Health and resposible parties had not happened.the state’s words, verbatim · CDSS document, Jul 22, 2021

Plan of correction: Facility has conducted staff meeting to include procedures that will ensure a care conference is conducted upon admission to home health services. Resident, responsible party , Home health and LVN of the facility will be present. ***POC Cleared***

Allegation investigated: Staff did not apprise resident's family of change in resident's condition Staff did not ensure that resident was adequately fed while in care

On 07/22/2021, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to deliver findings on the above allegation. During the course of the investigation, LPA conducted interviews with staff and reviewed records. LPA received documentation from Executive Director evidencing the family's notification and consent to place R1 on HospiceCare services due to a change of condition for R1. Facility records reveal annual documented weight records for 2017, 2018 and 2019. Hospital records show R1 is one pound heavier in weight than the three years prior. Facility’s procedures were reviewed. It was confirmed the facility contacted the physican and family to initiate Hospice Care. Based on interviews conducted and records reviewed, the allegation is UNFOUNDED. Therefore we have dismissed the complaint. No deficiency was observed. Exit interview conducted. No Deficiencies are being cited on todays visit. Exit interview conducted and appeal rights given. Unfoundedthe state’s words, verbatim · CDSS document, Jul 22, 2021 · control 24-AS-20201230161131

Allegation investigated: Staff did not prevent an altercation between residents in care.

On 07/22/2021, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to deliver findings on the above allegation. During the course of the investigation, LPA conducted interviews with staff and reporting party. The Department investigated the above allegation. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the allegation above is found to be SUBSTANTIATED. Deficiency is 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, Jul 22, 2021 · control 24-AS-20210609152018

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(1) · Plan of correction due date: Jul 22, 2021

87413 Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met as evidenced by interviews with staff and observation of police and facility reports.the state’s words, verbatim · CDSS document, Jul 22, 2021

Plan of correction: Executive Director has hired additional staff to provide additional supervision in the Alderbrook Memory Care. Facility requested R1 be seen by their physican for evaluation of behaviors. ** POC Cleared **