Carefield Pleasanton

Allegation investigated: Facility did not safeguard resident's personal belongings.

On 9/29/2023 at 10:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegation above. Upon arrival, LPA met with Assistant Executive Director, Eunice O'Farrell and explained to her the reason for the visit. During the course of the investigation, LPA conducted interviews with staff, residents, and complainant. Resident’s physician’s report, care plan, progress notes, LIC621, reimbursement information, and email correspondence were obtained and reviewed. LPA observed R1's progress notes stated that R1 was missing items including picture frames, clothing, iPod, and hearing aids with safety clips. LPA observed R1's LIC621 stated facility is entrusted with R1's hearing aids and safety clips. R1's hearing aids have safety clips that could be attached to R1's clothing. Interview with staff revealed that resident's belongings are usually labeled. Staff stated that hearing aids were not found and facility reimbursed R1's family for the cost of the hearing aids. (Continue LIC9099C...) Substantiated Resident suffered multiple falls resulting in injuries. Interview with staff revealed that R1 had six falls while living at the facility in which four falls resulted in injuries or minor injuries. However, after R1’s fall on 5/22/2022, the facility raised R1’s level of care from a two to a four which increased resident checks to eight times, R1 is checked every 30 minutes due to fall risk, and fall alarms was installed in R1’s room. Resident was not provided assistance with toileting needs Interview with staff indicated that toileting needs are checked at least every 2 hours. Staff have not witnessed resident's toileting needs were not met. Resident was not provided assistance with showering. Interview with staff revealed that R1 would sometimes refuse showers and staff come back at a later time to assist R1 with showers. Staff stated when a resident refused showers, it would be documented on the progress notes. Inadequate staffing to meet the needs of the residents in care. LPA reviewed staff scheduled and observed AM shift have 4-5 caregivers and 1 med tech, PM shift have 4 caregivers and 1 med tech, and NOC shift have 2 caregivers and 1 med tech. Interview with staff revealed that besides the caregivers and med techs, a manager is on duty for both AM and PM shift seven days a week. Staff did not respond to resident's call bell. LPA reviewed a sample of resident's pull cord records and observed pull cord incidents from R1 were responded by facility staff. Resident cannot easily use pull cord. LPA observed R4 demonstrated how to pulled on the pull cord beside the bed and was able to pull the pull cord. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 15-AS-20221229131014

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Oct 20, 2023

Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not safeguarding resident's belongings which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Facility has agreed to develop a plan to better safeguard resident's belongings in the future and submit plan to CCLD by POC date.

Type of visit: Case Management - Deficiencies

On 9/29/2023 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Assistant Executive Director, Eunice O'Farrell. During the course of investigation for complaint (#15-AS-20221229131014), the following deficiency was observed. Interview with staff (S2) revealed that facility did not always submit an incident report for R1's falls. LPA observed only 3 incident reports regarding R1's fall. However, R1 had other falls that was not reported to CCLD. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 20, 2023

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... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not reporting all of R1's falls which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Facility has agreed to conduct a training regarding reporting requirements. Facility will submit staff sign in sheet and training materials to CCLD by POC date.

Type of visit: Case Management - Annual Continuation

On 9/29/2023 at 2:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation. LPA met with Assistant Executive Director, Eunice O'Farrell and explained the purpose of the visit. During visit, LPA reviewed staff training and observed staff completed training which includes dementia, food service, resident rights, medication, hospice, ADL (Activities of Daily Living) care, and other topics. LPA interviewed 2 residents and 2 staff starting at 4:00PM. At around 5:30PM, LPA reviewed a sample of resident's medications. At 3:30PM, LPA observed facility does not have home health written agreement for a resident. At 6:00PM, LPA observed R4's doctor's order dated 4/11/2023 stated R4 is taking Acetaminophen 1000mg. However, LPA observed facility has a bottle of Acetaminophen 325mg. R4 also has a bottle of Acetaminophen 500mg. Facility has faxed R4's doctor the medication clarification/request and provided a copy to LPA during inspection. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 29, 2023

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 8/29/2023 at 9:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Memory Care Director, Narcisa Gordillo. The facility’s fire clearance was approved for 82 non-ambulatory residents, of which 9 may be bedridden, and 11 residents may be under hospice care. LPA toured the facility with Narcisa including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 1/9/2023. One week of nonperishable and 2-day of perishable food supplies were available. Facility orders food once a week. Freezer’s temperature was registered at -20 degree F while the refrigerator’s temperature was recorded at 36 degrees F. Grab bars for each toilet and shower were installed. Non-skid mats/materials were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 6/10/2023. LPA reviewed 5 resident records and 5 staff records starting at 11:06AM. (Continue on LIC809C...) At around 10:30AM, LPA observed hot water was measured at 126 degrees F in a resident's bathroom. Staff lowered hot water temperature. LPA re-measured hot water at 107.5 degrees F. At around 11:45AM, LPA observed R2 and R3 does not have TB test on file during record review. At around 12:30PM, LPA observed S4 does not have current First Aid training. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. LPA will return at a later time to complete the inspection. Exit interview conducted with Narcisa Gordillo. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 29, 2023

Type of visit: Case Management - Health Checks

On 12/30/2022 at 10:20AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with Assistant Executive Director, Eunice O'Farrell. LPA toured facility including but not limited to the resident bedrooms, bathrooms, common area, kitchen, and outdoor area. Facility temperature was maintained at 69 degrees F. Hot water temperature was measured at 120 degrees F in a resident's bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility order food supplies weekly. Refrigerator was 36 degrees F and freezer was -3 degrees F. Resident's medications were kept locked in the medication room. Smoke detectors are interconnected with sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full. There are no accessible bodies of water observed. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 30, 2022

Allegation investigated: Facility failed to provide adequate supervision resulting in resident pushing another resident.

On 7/28/2022 at 2:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegation above. LPA met with Business Office Director, Jocelyn Sanjuan. Senior Executive Director, Parveen Singh arrived a couple hours later. During the investigation, LPA interviewed 1 resident and 3 staff. LPA reviewed and obtained documents including staff schedule, incident report, physician's report, care plan, emergency information, and care notes for two residents. Interview with staff revealed that R1 was asking S2 for food right outside the kitchen door. R2 got up and approached S2 to ask for water. R1 turned the walker to block R2 from going closer to the kitchen door. R2 pushed R1 lightly and said "excuse me". R1 loss balance and fell down. LPA reviewed staff schedule and observed there was 4 caregivers and 1 med tech on duty during incident. (Continue on LIC9099C...) Unsubstantiated Interview with resident revealed that R2 did not remember what happened on 5/12/2022 or the incident between R1 and R2. LPA reviewed R1 and R2's records and observed both residents did not require 1:1 care and supervision. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jul 28, 2022 · control 15-AS-20220513164341

Type of visit: Case Management - Incident

On 7/28/2022 at 12:55PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 7/26/2022. LPA met with Business Office Director, Jocelyn Sanjuan. Senior Executive Director, Parveen Singh arrived a couple hours later. Death report dated 7/26/2022 stated that R1 was found unresponsive on 7/22/2022 and staff called paramedics. R1 has a DNR on file. R1 passed away at the facility on 7/22/2022. During visit, LPA reviewed R1's file and observed physician's report dated 7/15/2022 stated that R1's primary diagnosis was Cerebral Infarction affecting right dominant side, Dysphagia, and CHF. R1's secondary diagnosis was Chronic Kidney Disease and Vascular Dementia. Facility notes indicated that R1 did not eat much for a couple days prior to passing. Interview with staff indicated that R1 did not eat much prior to moving into the facility. Paramedics pronounced death on 7/22/2022. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jul 28, 2022

Type of visit: Required - 1 Year

On 7/14/2022 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Senior Executive Director, Parveen Singh and Assistant Executive Director, Eunice O'Farrell. LPA explained the purpose of the visit. Upon entry, LPA's temperature was checked and asked to fill out COVID-19 questionnaire on the automated kiosk. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor area. LPA observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All bathrooms were equipped with soap and paper towel. Hand washing posters were posted at bathrooms. During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPEs, food supplies, and paper supplies are sufficient. Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102. No deficiencies were cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jul 14, 2022

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.