Masonic Homes for Adults

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced annual inspection visit. LPA met with Administrator Vincent Gonzaga and shortly with Donato Rodriguez / Facility Director, whom assisted with the visit. The facility is licensed to serve one hundred & twelve (112) non-ambulatory residents, ages 60 and above. The facility has an approved five (5) hospice waivers. Currently (0) residents are on hospice. 23 Independent residents and 28 assisted living residents. During the visit, the CARE tool was used, a tour of the facility was conducted with Donato. The facility locates at a residential neighborhood, consists of three (3) buildings with fifty-six (56) resident rooms. Food supply was reviewed sufficient perishable and non-perishable food items observed, total of 3 freezers and 3 refrigerators, thermometers in place. Separate room in kitchen for locked cleaning solutions and disinfectants. LPA Calderon alongside with LVN Jacqueline Giron reviewed Medication Record and medications for a total of 4 residents. 23 residents need assistance with medication and are stored in med room, no deficiencies were observed. Medication Room had sufficient PPE. Resident rooms consists of a bedroom, living room, dining area, kitchen, bathroom and walk-in closet. LPAs visited resident rooms #A-108, A-113, B-103, B-106, and C-102,C-106 and C_112. Bathrooms are clean and operable with grab bars and non-skid surface mats/strips. Hot water temperature is in a range of 111.1 to 119 degrees Fahrenheit which is within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies are in stock in Building M1. Total of 4 laundry rooms for residents and one laundry room for staff use. (Continuation on LIC 809 C-) The facility has six (6) administrative offices, a reception area/lobby, beauty salon, wellness center, 3 libraries, coffee/reading room, hospitality room, dining room, kitchen, mail room, communication room, ceramic room, aviation room, thrift store, activity /game room/painting/card making room, general store, housekeeping storage room, lactation room, computer lab, nurses station, bingo room, exam room, staff lounge, and recovery room. There are multiple storage closets/rooms and an indoor/outdoor activity area. The facility has fifteen (15) public restrooms which are clean and operational. Smoke alarms are tested quarterly using TRL Service and Testing Company and wired to the Fire Department of Covina. Carbon monoxide detectors are operable. Fire extinguishers were located throughout the facility, extinguishers were serviced and charged. Fire Drill conducted on 7/11/23. Elevator is operable and available for residents' use. Signal systems in resident rooms are operable. Swimming pool and jacuzzi are empty with no water, locked and gated. No bodily of water are observed in the facility. The first aid kits observed and located in Wellness Center, Kitchen, and Med Room are fully stocked with a manual. The outdoor activity area is free of visible hazards and debris. There is shaded patio and garden areas with ample seating. Facility landline phone is operable for residents' use. Administrator certificate is current with expiration date of 09/12/2023 for Vincent Gonzaga. Nursing Home Administration Expiration date: August 31, 2023. LPA Calderon review 5 resident files alongside with Executive Assistant Anabel Mejia and 5 staff files. All appropriate documentation's were filed, staff are clear and no deficiencies noted. A total of 4 residents were interviewed and 1 staff interview was conducted. Liability insurance expires: April 1, 2024 No deficiencies were observed during today's inspection. An exit interview was conducted. A copy of this report was provided to Vincent Gonzaga.the state’s words, verbatim · CDSS document, Jul 11, 2023

Allegation investigated: Staff threatened physical harm to resident

Licensing Program Analyst (LPA) Ashley Calderon conducted a unannounced complaint visit to investigate the above allegation. LPA met with Administrator Sandra Fahey and explained the reason for the visit. On 11/12/22, LPA Long conducted an interview telephonically with Staff #1 (S1) and requested a copy of the Staff/Resident Roster. On 7/20/22 LPA Calderon conducted an investigation and it consisted of the following: LPA Calderon interviewed residents #2 - #11(R2 - R11) and interviewed staff #1-#10 (S1-S10). Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Staff threatened physical harm to resident" it was alleged that S2 threatened R1 by demonstrating how S2 would kick him. (10) of (10) residents stated they are not aware of any residents being threatened by staff and staff treat them okay, great, friendly, nice and respectful. (10) of (10) staff stated they are not aware of any residents who were threatened . 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. An exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 20, 2022 · control 28-AS-20201105113734

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Valeria Maldonado conducted an unannounced visit to the above mentioned facility. The reason for the visit was to reissue a citation that was issued on 06/10/2022 and will reflect the correct regulation under which it will be cited. The citation will remain unchanged. LPA Maldonado met with Administrator Sandra Fahey today, and explained the reason for the visit. During the 06/10/2022 visit, LPA Maldonado obtained a copy of the resident and staff roster. While reviewing file for Staff #1 (S1), it was discovered that S1 had been employed at the facility since 04/18/2016 and had a criminal record clearance, but was not associated to the facility. S1 was associated on 06/09/2022. Administrator stated that S1 was initially associated to the wrong facility. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D. Immediate Civil Penalties in the amount of $500 were issued on today's visit. The report and appeal rights were discussed with the administrator and a copy of each were provided.the state’s words, verbatim · CDSS document, Jun 14, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jun 14, 2022

Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement was not met as evidenced by: During S1's file review, it was discovered that S1 was cleared and not associated to facility since employment on 04/18/2016. S1 was assciated on 06/09/2022, which posed an immediate Health and Safety risk to clients in care. Civil Penalties were assessed in the amount of $500.the state’s words, verbatim · CDSS document, Jun 14, 2022

Plan of correction: Cleared on 06/09/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jun 14, 2022

Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement was not met as evidenced by: During S1's file review, it was discovered that S1 was cleared and not associated to facility since employment on 04/18/2016. S1 was assciated on 06/09/2022, which posed an immediate Health and Safety risk to clients in care. Civil Penalties were assessed in the amount of $500.the state’s words, verbatim · CDSS document, Jun 14, 2022

Plan of correction: Cleared on 06/09/2022.

Allegation investigated: Staff is retaliating against a resident while in care. Resident is not afforded privacy while in care. Staff threatens a resident while in care. Staff is interfering with a resident's medical needs.

Licensing Program Analyst(LPA) Valeria Maldonado conducted a subsequent unannounced complaint investigation visit regarding the above mentioned allegations. The initial visit was conducted telephonically by LPA Tao on 01/29/21, who met with administrator Judy Figueroa. LPA Maldonado met with administrator Sandra Fahey today and explained the reason for the visit. The investigation consisted of the following: 1 staff and 1 resident were interviewed during the initial complaint visit. LPA requested the following records for Resident #1’s (R1) to Resident #6 (R6): Physician report; Identification and Emergency information; Appraisal; and Need and service plan. LPA also requested R1’s Incident reports from April 2020 to current, complaint notes from R1, R1’s eviction letters from 2020 to current, documents regarding where surveillance cameras are installed, and document about where cameras are focusing on. The investigation revealed the following: Allegation- Staff is retaliating against a resident while in care. (Report continued on LIC9099-C...) Unsubstantiated R1 stated the facility installed cameras as a form of retaliation against them. (8) of (9) residents interviewed stated they have not been, and have no knowledge of any resident being retaliated against by staff at the facility. A review of the surveillance videos conducted during the visit revealed that all (36) cameras are used to record roadways, hallways, parking lots,and common areas. None are focused on resident apartments. Although the allegations may have happened or are valid, there is not a preponderance of evidence standard to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation- Resident is not afforded privacy while in care. R1 stated that a surveillance camera was installed pointing directly at their window. A review of the surveillance videos conducted in the maintenance facility offices revealed that all (36) cameras are used to record roadways, hallways, parking lots, and common areas. The camera that was alleged to be installed to record R1's window is focused on the roadway behind their home and happens to catch part of their window as part of the picture. (8) of (9) residents interviewed stated they feel comfortable and are given their privacy by all staff. Although the allegations may have happened or are valid, there is not a preponderance of evidence standard to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation- Staff threatens a resident while in care. R1 stated that Staff #3 (S3) was harassing/threatening R1 by following them in the facility golf cart with no headlights on. A letter was obtained by the facility regarding an interview conducted with S3 and R1 by Staff #1 (S1) indicating the matter was addressed. S#3 admitted to driving with no headlights on as to not bother R1's eyes, not to harass/threaten them. The lights were turned immediately on again after passing R1. (8) of (9) residents interviewed stated they have never been harrassed or felt threatened by any staff at the facility. Although the allegations may have happened or are valid, there is not a preponderance of evidence standard to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation- Staff is interfering with a resident's medical needs. R1 stated they requested to make an appointment with their doctor and S1 told Staff# 4 (S4) to not make the appointment for them. Interview with S1 and S4 indicated that medical requests/needs were never refused. S1 was independent and did not need assistance with ADL's. (8) of (9) residents interviewed stated S4, nor any staff, have ever refused to assist with any medical needs/requests. Although the allegations may have happened or are valid, there is not a preponderance of evidence standard to prove the allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Sandra Fahey and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 10, 2022 · control 28-AS-20210122162233

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Valeria Maldonado conducted an unannounced visit to the above mentioned facility. LPA met with administrator Sandra Fahey and toured the facility. During the visit, LPA obtained a copy of the resident and staff roster. While reviewing file for Staff #1 (S1), it was discovered that S1 has been employed at the facility since 04/18/2016 and was not associated to the facility until 06/09/2022. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Jun 10, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80019(e)(1) · Plan of correction due date: Jun 13, 2022

Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement was not met as evidenced by: During S1 file review, it was discovered that S1 was not associated to facility since employment on 04/18/2016. S1 was assciated until 06/09/2022 and this caused an Immediate Health and Safety risk to clients in care. Civil Penalty assessed $500.the state’s words, verbatim · CDSS document, Jun 10, 2022

Plan of correction: The facility will ensure all staff members are fingerprint cleared and associated prior to working or being present at the facility. The licensee will submit a plan of action on how they will ensure individuals will not be present at the facility until they are cleared by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Tao, Calderon and Maldonado conducted an unannounced annual inspection visit. LPA met with Administrator, Sandy Fahey, and Facility Director, Bobbie Dimmitt, both assisted with the visit. The facility was licensed to serve one hundred & twelve (112) non-ambulatory residents, ages 60 and above. The facility had an approved five (5) hospice waivers. Currently, three (3) residents are on hospice. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility locates at a residential neighborhood, consists of three (3) buildings with fifty-six (56) resident rooms. Resident rooms consists of a bedroom, living room, dining area, kitchen, bathroom and walk-in closet. LPAs visited resident rooms #A-104, A-110, B-109, B-113, and C-112. Bathrooms are clean and operable with grab bars and non-skid surface mats/strips. Hot water temperature is in a range of 107.7 to 117.9 degrees Fahrenheit which is within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies are in stock. The facility has six (6) administrative offices, a reception area/lobby, beauty salon, wellness center, 3 libraries, coffee/reading room, hospitality room, dining room, kitchen, mail room, communication room, activity /game room/painting/card making room, general store, housekeeping storage room, dental office (vacant), computer lab, nurses station, bingo room, exam room, staff lounge, and recovery room. There are multiple storage closets/rooms and an indoor/outdoor activity area. (-continued in LIC 809 C-) The facility has fifteen (15) public restrooms which are clean and operational. There are four (4) residential laundry rooms and a maintenance laundry room. Sufficient supply of perishable and nonperishable foods were observed. Smoke and carbon monoxide detectors are operable, monitored by a fire alarm company which the last fire alarm inspection is conducted on 02/25/22. The facility has total of 85 fire extinguishers and LPAs checked ten (10) of them which are fully charged and last service was on 05/10/22. Elevator is operable and available for residents' use. Signal systems in resident rooms are operable. Swimming pool at the yard, pond at patio and jacuzzi at the first floor are empty with no water. They are locked, inaccessible to residents and surrounded with a 6-ft high fence. No bodily of water are observed in the facility. The first aid kit is fully stocked with a manual. All mandated documents and signages are posted in common areas. The outdoor activity area is free of visible hazards and debris. There is shaded patio and garden areas with ample seating. Medications are centrally, stored and locked and records are current. Fire/ Emergency drill conducted on 04/18/22. Facility landline phone is operable for residents' use. Administrator certificate is current with expiration day on 03/03/2023. Exit conference was conducted. A copy of LIC 809s was provided.the state’s words, verbatim · CDSS document, May 20, 2022