North Lake Villas

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced Required One (1) year - Infection Control inspection at this facility. LPA met with staff Maria Heredia who called the administrator and explained the reason for the visit. The administrator designated Maria Heredia to sign the report. A tour of the physical plant was conducted at 9:30 AM and the following was noted: There is only one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet and hand sanitizer is available. LPA was screened upon entry. All the staff were observed to be wearing mask. The facility had submitted and approved Mitigation Plan and Infection Control Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has multiple screening stations all through out the facility. The facility has sufficient stock of PPE in the storage room. The facility has fifteen (15) bedrooms and nine (9) bathrooms in multiple interconnected residential type building. The facility is fire cleared for thirty (30) non-ambulatory residents, twenty three (23) of which maybe bedridden in rooms 1 to 15. Hospice waiver for ten (10) residents. (continued on LIC 809-C) (continued from LIC 809) Living and dining rooms furniture were checked. The living rooms were neat, clean and in proper order. The facility maintains a comfortable temperature at 75°F. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 11/02/22. The facility is equipped with sprinkler system. There is no body of water at the facility. Passageways were observed to be clear from obstruction. Laundry area is located in the lower level. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet inaccessible to the residents. Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents. The residents rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit. The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at a range of 108.3°F to 118.2°F. There were enough clean linen available in the closets. Medications were kept in a medication cart located in the medication room adjacent to the kitchen. The medications were observed to be locked and inaccessible to residents. There were two ( 2) complete first aid kits located in an office adjacent to the kitchen. Staff and residents records were reviewed and appeared to be complete and updated. There is no health and safety issue observed during this visit. Exit interview conducted. A copy of this report issued.the state’s words, verbatim · CDSS document, Jan 14, 2023

Allegation investigated: Facility staff made resident wait in the cold basement of the facility before being moved out.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Assistant Administrator Adam Braun. The purpose of the visit was discussed. It was reported that facility staff made resident wait in the cold basement of the facility before being moved out. To investigate this allegation on 11/09/2022, between 12:40pm and 1:30pm, staff interviews were initiated. Interviews revealed that R1 was taken to the bottom floor of the facility and not the basement. Staff interviewed do not know why R1 was taken to the bottom floor of the facility prior to being relocated. Between 1:30pm and 2:00pm, records were reviewed. A Welebhealth staff confirmed that they were made to wait in a cold basement prior to R1's exit of the facility. Continue on C 9099 Substantiated This is an amended copy of the report previously issued on 11/09/2022. The signatures were not recorded. Based on interviews and record review there is not sufficient information to support this allegation. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. It was alleged that facility staff did not inform resident's DPOA prior to cutting resident's hair. To investigate this allegation on 11/09/2022, between 12:40pm and 1:30pm, staff interviews were initiated. Interviews revealed that R1's niece came to the facility on 10/17/2022 and took them to get a hair cut. On 10/20/2022 a small piece of gum got stuck to R1's hair. Staff attempted to remove it manually, but were unable to. Staff proceeded to cut the strand of hair that had gum on it. Staff did not cut all of R1's hair. Based on interviews there is not sufficient information to support this allegation. Therefore, this allegation is deemed to be UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued. This is an amended copy of the report previously issued on 11/09/2022. The signatures were not recorded. Based on interviews and records review there is sufficient information to support this allegation. Therefore, this allegation is being SUBSTANTIATED at this time. Deficiency cited. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 9, 2022 · control 31-AS-20221104084618

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(5) · Plan of correction due date: Nov 16, 2022

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...(5) To be accorded safe, healthful, and comfortable accommodations... This requirement was not met as evidenced by: The Licensee did not ensure that the personal rights of R1 were respected. R1 was not accorded comfortable accommodations while waiting to move out of the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 9, 2022

Plan of correction: The Licensee shall submit in writing to CCLD by 11/16/2022, how they will ensure that all residents in care personal rights will be respected.

Allegation investigated: Resident was not provided a copy of their Admissions Agreement while in care. Facility failed to keep premises free from obstructions.

At approximately 12:00 p.m. on 06/07/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with administrator and disclosed the reason for the visit. Resident was not provided a copy of their Admissions Agreement while in care. Regarding the allegation above, it was alleged the facility did not provide resident #1 (R1) with a signed copy of their admission agreement for over 4 months. To investigate, LPA Manya Lefian interviewed R1 and LPA Nicholas Reed interviewed staff #1 (S1) and staff #2 (S2) at 12:15 p.m. on 06/07/2022. LPA Lefian suggested R1 ask again for the admission agreement, and R1 confirmed it was provided. S1 informed LPA Reed that R1 already had a copy of their admission agreement. S2 told LPA Reed that R1 was provided a copy of the agreement on the day R1 moved to the facility. Based on interviews, the facility did provide the admission agreement to R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegation is deemed UNSUBSTANTIATED at this time. Unsubstantiated Facility failed to keep premises free from obstructions. Regarding the allegation above, it was alleged that furniture belonging to a female resident blocked R1’s path to the bathroom. To investigate the allegation, LPA Lefian interviewed R1 on 06/12/2020 and LPA Reed interviewed S1 and S2 at 12:15 p.m. on 06/07/2022. S2 also toured the facility with LPA Reed at approximately 12:40 p.m. R1 told LPA Lefian that the facility “cooperated and moved her area and the table she uses so I don't have that issue anymore”. S2 explained to LPA Reed that the large chairs which blocked R1’s path were replaced with smaller chairs immediately. During the visit, LPA observed the large chairs were no longer obstructing the walkway and were moved to the side of the room. LPA observed no other obstructions. Based on interviews and observations, the facility promptly moved the obstructions from R1’s path. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations. Therefore the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 7, 2022 · control 31-AS-20200605111033

Allegation investigated: Staff threatening resident with eviction. Resident's needs are not being met.

At approximately 12:00 p.m. on 06/07/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with administrator and disclosed the reason for the visit. Staff threatening resident with eviction. Regarding the allegation above, it was alleged the facility threatened to evict resident #1 (R1). To investigate the allegation, LPA Manya Lefian interviewed staff #1 (S1) at 9:49 a.m. on 06/05/2020 and LPA Reed interviewed S1 at 12:30 p.m. on 06/07/2022. LPA Reed also conducted a record review on 06/07/2022 at 12:58 p.m. S1 told LPA Lefian the facility “did not threaten [R1] with an eviction” and needed to find R1 a higher level of care due to a worsening stage 2 pressure injury. From record review, home health notes from 06/05/2020 indicated a primary diagnosis of “pressure ulcer of right buttock, stage 2” and a secondary diagnosis of “pressure ulcer of other site, stage 2”. Due to R1’s large size, S1 and S2 conducted a body scan on R1. S1 and S2 determined the wound was greater than stage 2 and called for medical transport for R1. Unsubstantiated Based on interview and record review, R1 needed a higher level of care than the facility offered to treat R1’s pressure ulcers. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegation is deemed UNSUBSTANTIATED at this time. Resident's needs are not being met. Regarding the allegation above, it was alleged staff did not assist R1 with bathing or incontinence needs. To investigate the allegation LPA Lefian interviewed S1 at 9:49 a.m. on 06/05/2020 and LPA Reed interviewed S1 and S2 at 12:15 p.m. on 06/07/2022. S1 told LPA Lefian that the facility offered to remove R1’s excrement. The facility has also offered to bathe R1, yet R1 refused. S2 told LPA Reed the facility constructed an extra large toilet seat to accommodate R1. S1 told LPA Reed R1 always refused bathing and assistance with toileting. Based on interviews, the facility offered R1 adequate assistance with bathing and toileting. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 7, 2022 · control 31-AS-20200527082812

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year-Infection Control inspection to the facility. LPA met with Adam Braun, Director of Operations and explained the reason for the visit. A tour of the physical plant was conducted at 10:10am and the following was noted: There is only one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet and hand sanitizer is available. LPA was screened upon entry. The facility had submitted and approved Mitigation Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has sufficient stock of PPE in the storage room. The facility has fifteen (15) bedrooms and nine (9) bathrooms currently occupying twenty-three (23) residents. (continued on LIC 809-C) Living and dining room furniture were checked. The living room is neat and clean. The facility maintains a comfortable temperature at 76 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguishers are located throughout the facility. There is no body of water at the facility. Passageways were observed to be clear from obstruction. Laundry area is located in the lower level. Laundry detergents, cleaning agents and other toxins are stored in a cabinet which was observed to be locked. Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents. The residents rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit. The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 111.2 degrees F. There was enough clean linen available in the closets. Medications-LPA observed medication cart to be locked and inaccessible to residents. There were two ( 2) complete first aid kits located in an office adjacent to the kitchen. No deficiencies are cited at this time. Exit interview conducted. A copy of this report was issued and signature obtained.the state’s words, verbatim · CDSS document, Jul 29, 2021