Annabelle's Cottage

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by Caregiver. The Administrator was at an appointment; however, LPA Spaeth spoke to the Administrator via phone at 9:30 am. The facility is licensed as a Resident Care Facility for the Elderly to serve five residents of which five may be non-ambulatory and one bedridden. There are three residents living in the facility. LPA reviewed residents' records at 9:40 am until 10:15 am. LPA and Caregiver began the tour of the facility at 10:20 am until 11:00 am. LPA observed the following: Kitchen – LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. LPA observed the knives were locked in a kitchen drawer and medications were locked in the kitchen cabinet. The fire extinguisher is located in the kitchen area. Common areas – LPA Spaeth observed the living room and dining room combination contained comfortable seating and a dining room table with chairs. LPA observed the family room also contained comfortable seating and a television. Bathrooms – LPA Spaeth observed both bathrooms contained hand soap, paper towels, slip resistant mat, and a trash can. Water temperature was tested at 10:45 am at 122.0 F. Bedrooms – LPA Spaeth observed there are three bedrooms in the facility and two of the bedrooms are occupied by residents. The bedrooms contained bed, linens, night stand, and night lamp. Laundry Room – LPA Spaeth observed the laundry room was locked. The washer/dryer, cleaning supplies, and laundry soap are safely locked in the laundry room. Backyard – LPA Spaeth observed comfortable seating in a shaded area. The side gate leading from the backyard to the front yard was not locked. Smoke/Carbon Monoxide Detectors – The smoke detectors were tested at 10:50 am. The carbon monoxide detector is operational and located in the family room. Delayed Egress System- LPA Spaeth observed the delayed egress system was properly working on all five exit doors. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to caregiver.the state’s words, verbatim · CDSS document, Aug 2, 2023

Type of visit: Case Management - Other

LPA Spaeth conducted an unannounced visit and stated the purpose of the visit was to conduct a case management visit to tour the facility. LPA was greeted by caregiver. LPA observed two caregivers working at the facility and observed both were wearing masks. LPA and caregiver began the tour at 12:10 pm until 12:35 pm. LPA observed the living room contained comfortable furniture. Upon walking into the kitchen/family room, LPA observed a resident listening to music in the family room. Kitchen area - LPA observed the knives and medications were locked in kitchen cabinets. The facility contained a seven-day supply of canned goods and a two-day supply of perishable food items. A fire extinguisher was located in the kitchen. Resident Bedrooms - LPA observed three residents in their rooms. The rooms were clean and were furnished with the appropriate furnishings. Bathrooms - LPA observed the bathrooms contained grab bars, slip resistant mats, hand soap, paper towels, and trash cans with fitted lids. Laundry room - LPA observed the laundry room was locked and contained laundry soap and cleaning solutions. There are no deficiencies to report at this time. Exit interview was conducted and a copy of the report was given to the caregiver.the state’s words, verbatim · CDSS document, Mar 8, 2023

Type of visit: Office

An Informal Conference was conducted today in the Woodland Hills Adult and Senior Care Regional Office. The purpose of this Informal Conference is to discuss a complaint regarding the allegations Resident (R1) sustained unexplained injuries while in care and resident wandered away from the facility. Prior to the meeting, Administrator was given the chance to review the facility file. Present at today's meeting are the following: · Anne Gregorio - Administrator · Cassandra Harris, Licensing Program Manager (LPM) · Melissa Spaeth, Licensing Program Analyst (LPA) The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions. BRIEF HISTORY: Facility has been in operation since licensure on June 30, 2004 for a maximum of five (5) residents. LPM Harris discussed and expressed concerns regarding the April 1, 2022. A complaint investigation was conducted by Investigations Branch Investigator Christine Ferris and Heidy Bendana regarding the allegation resident sustained unexplained injuries while in care. Based upon the physician's report dated 3/16/2022 and residents' interviews, the allegation was unfounded. On October 6, 2022, LPA Spaeth conducted a complaint investigation and interviewed the caregiver who confirmed R1 left the facility at approximately 7:30 am on 4/01/2022 and the caregiver was unaware that the resident had been absent for approximately three hours. Caregiver stated R1 had knocked on a neighbor's door and the neighbor brought R1 back to the facility at approximately 10:30 am. Therefore the allegation, resident wandered away from the facility was substantiated. During LPA’s visit, LPA observed the cleaning supplies and the laundry detergent were not securely locked in the laundry room. LPA observed the caregiver locking the items in a kitchen cabinet. An annual was conducted on 6/24/2022 and LPA observed there were no non-skid mats located in the two bathrooms. The Administrator corrected the deficiency by forwarding snapshots of the bathrooms. Licensing Program Analysts (LPA’s) Spaeth, Avetisyan and Stamps conducted an annual on 9/30/2021 and deficiencies were issued regarding the following categories: incomplete resident files, lack of food, inoperable carbon monoxide/smoke detectors, staff first aid training, Administrator qualifications, sufficient staffing, centrally stored medication records, active corporation status, and liability insurance. Administrator agreed to provide a new LIC 500 and updated elopement plan of care to ensure safety of the residents. Licensee will provide these reports to CCL by November 28, 2022 via email. The Licensee was informed that Community Care Licensing (CCL) shall continue to frequently monitor the facility as often as necessary to ensure the Licensee's compliance with Title 22 Regulations. Exit interview conducted, and a copy of the report was issued to the Caregiver.the state’s words, verbatim · CDSS document, Nov 15, 2022

Allegation investigated: Resident wandered away from the facility

LPA Spaeth conducted an unannounced visit and was greeted by two caregivers. LPA's temperature was recorded and COVID questions were completed by LPA. LPA stated the purpose of the visit was to complete the investagation regarding two allegations which are resident sustained unexplained injuries while in care and resident wandered away from the facility. LPA reviewed resident's file at 10:30 am until 10:40 am. LPA interviewed caregiver at 10:40 until 10:55 am who was working at the facility on the day that the alleged allegation occurred. During the interview, the caregiver stated was not aware that Resident (R1) had walked out of the facility on 4/01/2022 at approximately 10:30 am. Based upon LPA's interview of the caregiver, this allegation is substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D). LPA Spaeth Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to Administrator. Substantiated R1 allowed investigators to take pictures of the bruises on arms. Investigators observed the bruising was on R1’s elbows, wrists, and sporadically along forearms on both arms. The Investigators also reported the bruises on R1’s arms were not indicative of being grabbed or hit and there were no hand or finger imprints on R1’s arms. The bruises did not appear concerning and were not consistent with physical abuse. Investigators Ferris and Bendana also interviewed staff member (S1) who stated has been working at the facility since November of 2021. S1 stated they have not witnessed or heard of any abuse or neglect in the facility. Based on the information collected and interviews of residents and staff member, there is not sufficient evidence to substantiate the allegation. Therefore, the allegation is Unfounded. “This agency has investigated the complaint alleging “resident (R1) sustained unexplained injuries while in care.” This allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basisthe state’s words, verbatim · CDSS document, Oct 6, 2022 · control 31-AS-20220405104144

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a)(2) · Plan of correction due date: Oct 12, 2022

Personal Rights (a) Residents in residential care facilities for the elderly shall have personal rights...(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was evidenced by: The resident wandered away from the facility at about 10:30 am on 4/01/2022 and brought back to the facilty by a neighbor. Also, based upon LPA interviewing the caregiver, the resident to leave the facility without supervision which is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Administrator will submit a written plan as to what steps will be taken to ensure residents who are not able to leave the facility unannisted do not. Administrator will also submit a signed document which states caregivers received training from the Administrator regarding the written plan.

Type of visit: Case Management - Other

LPA Spaeth conducted an unannounced visit regarding Complaint #31-AS-20220405104144. LPA began tour of the facility with caregiver at 9:55 am. Upon touring the laundry room at 10:17 am, LPA observed the laundry room door was not locked. LPA observed the cleaning supplies and the laundry detergent were not securely locked in the laundry room. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D). LPA Spaeth Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to Administrator.the state’s words, verbatim · CDSS document, Oct 6, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(f) · Plan of correction due date: Oct 6, 2022

87705Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives...(2) Over-the-counter medication, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, the licensee failed to ensure cleaning supplies (toxins) were inaccessible to dementia residents which poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: This item was secured during LPA's inspection and a new battery was added to the door lock. LPA confirmed the door was locked.

Type of visit: Required - 1 Year

LPA Spaeth conducted an unannounced visit to the facility and was greeted by caregiver. LPA was asked to record temperature and answer COVID questions. LPA observed the sign in station which contained thermometer, hand sanitizer, and sign in sheet with COVID questions. LPA also observed another caregiver who was wearing a mask. LIving Room/Dining Room Area - LPA observed comfortable seating in the living room along with dining room furniture. The room was comfortable and clean. Family Room/Kitchen Area - LPA observed a resident watching television in the family room and saw the room contained comfortable furniture. LPA observed there were no harmful chemicals in the cabinet beneath the sink. The medications and knives were locked in the kitchen cabinets. LPA observed the refrigerator contained a five-day supply of fresh fruits and vegetables, eggs, and other dairy products. The freezer contained frozen meats and vegetables. The sink area contained wash your hands sign, paper towels, and hand soap. The pantry was neat and well-stocked with a seven-day supply of canned goods and other dry good items. Backyard area -LPA observed a shaded area in the backyard which contained comfortable seating. The side gate was not locked that leads from the backyard to the front yard. The backyard was also neat and clean. Hallway area - LPA observed two hall closets which contained clean linens, an adequate supply of PPE items, and diapers. Residents' Rooms- There are four resident rooms and three are occupied. Each room contained bed, linens, chest of drawer, closet, night lamp, night stand and a chair. Each room was neat and clean. Locked Laundry Area - LPA observed the locked laundry area which contained laundry detergent, cleaning supplies, washer and dryer. A door within the room led to the garage which contained additional storage items and an additional refrigerator which contained eggs and frozen meats. Bathrooms - There are two bathrooms in the facility. Both bathrooms contained wash your hands sign, hand soap, paper towels, and a trash can. The Caregiver explained one bathroom is used for showering residents; however, the bathroom did not contain a slip resistant mat. Under Title 22 General Regulations, the following citation was issued and recorded on LIC 809D. Exit interview was conducted, appeal rights discussed and LPA gave a copy of the report during the visit.the state’s words, verbatim · CDSS document, Jun 24, 2022

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Jun 27, 2022

87303 Maintenance and Operation (3) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: LPA Spaeth observed there are no non-skid mats located in the two bathrooms, which is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2022

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA’s) Spaeth, Avetisyan and Stamps conducted an unannounced visit to the facility. Upon arrival LPA’s observed the front door did not contain the COVID signage. LPAs were greeted by Ringo Torres Caregiver at 11:19 am. Upon entering the facility, LPA’s observed the sign in station which contained thermometer, hand sanitizer and a sign in sheet. LPA Spaeth reminded the caregiver the requirement to take LPAs temperature. All LPAs temperatures were then taken and recorded. Caregiver called the licensee who arrived at the facility approximately 11:55 am. The initial purpose of the visit was to determine if Resident 1 (R1) who was named in an unlicensed care complaint was living at this facility, however during the visit LPA’s observed various deficiencies and determined that a required Annual Visit would be conducted as well. Approximately 11:25 am LPAs conducted a tour of the facility and observed a living room/dining room combination. As well as a kitchen/family room combination. The facility has four rooms designated for resident use and 2 residents residing at the facility. All resident rooms contained the required furnishing and proper linens. At 12:00 pm, LPAs observed full bed rails in Room #4 and 1/2 bed rails in Room #1. During the tour LPA’s observed that the master bathroom did not have the "wash your hands" sign not posted. LPA’s observed slip resistant mat and hand bars near the toilet and shower. LPA Spaeth informed staff that a "wash your hands" sign needs to be posted in the bathroom. The facility has a separate locked laundry room which contained washer and dryer, cleaning supplies, and laundry detergent. While conducting a tour of the kitchen LPA” s observed knives and medication properly secured. The refrigerator was observed to be dirty at which time LPA Spaeth informed the caregiver that the refrigerator will need to be cleaned. LPA’s did not observe sufficient supply of fruits and vegetables as well as insufficient supply of 7-day non-perishable food. LPA Spaeth informed the licensee of the deficiency. Approximately 11:54 am LPA Avetisyan requested the assistance of caregiver to test the smoke/carbon monoxide detectors. During the test LPA Avetisyan and Stamps observed that the 2 smoke detectors and 2 carbon monoxide detectors were not operational. A discussion was held with the licensee regarding the zero-tolerance deficiency as well as concerns of the alarms on all exit doors not working. The licensee informed the LPA’s that the alarm system was disconnected by staff approximately 2 months ago due to issues with the system. At 12:15 pm, LPA Avetisyan conducted review of resident facility and hospice files. LPA requested to see the facility file for resident 2 various times which the licensee and caregiver could not locate. While reviewing the hospice files, LPA Avetisyan did not observe a current hospice care plan for both residents. Approximately 12:30 pm LPA’s conducted a tour of the backyard and observed an electric table saw, screwdriver, dis-assembled bed, dirty mattress, 2 Hoyer lifts and various other items. Administrator was reminded that these items are a safety issue for the 2 residents in care. Approximately 1:00 pm LPA’s requested to review the medication records for resident. Licensee and staff searched but could not locate the file. Approximately 1:30 pm LPA’s conducted review of staff files and observed that staff do not have current first aid/CPR, have not received training since 2017. At 1:45 pm LPA asked the licensee how many staff she has working at the facility. Licensee informed LPA that she has 2. Staff Ringo Torres works at the facility Monday through Friday and another staff works at the facility on the weekends. LPA asked the licensee where the caregiver sleeps. Licensee informed LPA that the staff sleep in the converted staff room in the garage. At 2:23 pm LPA Avetisyan and Stamps requested for the administrator to show them the staf room. LPA’s along with caregiver walked to the laundry room, entered another door in the laundry room to the garage. To the left of the garage LPA’s observed 2 separate rooms which licensee confirmed is being utilized by the 2-current staff. LPA’s observed baby monitor hanging from the garage refrigerator. At 2:26 pm caregiver stated that monitors are used to supervise the residents at night. At 2:30 pm LPA Avetisyan requested to review the file for the administrator which the licensee could not provide. At 2:40 pm LPA called the administrator on record who stated that she no longer works for the licensee and has not worked since the start of the pandemic. LPA’s asked the licensee to explain why she lied to them about the administrator, which the licensee could not provide an answer. A discussion was held with the licensee regarding the seriousness of the deficiencies observed and cited, the immediate health and safety concerns for the residents in care and the current inactive status of the corporation. Licensee was informed that she will need to ensure that all deficiencies are corrected immediately which the licensee indicated she would Exit interview conducted, copy or report, citations, civil penalties and appeal rights emailed to ANNILISCIOUS@GMAIL.COM.the state’s words, verbatim · CDSS document, Sep 30, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(3) · Plan of correction due date: Oct 11, 2021

87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record... This requirement was not met as evidenced by: LPA reviewed resident file and did not find a written order for the resident's half bed rails.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Administrator will obtain a current hospice care plan which indicates the need for the postural support.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: Oct 11, 2021

87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently on hospice care and..hospice care plan that specifies the need for full bed rails.This requirement was not met as evidenced by: Licensee did not comply with the section cited above by utilizing full bedrails for R1 who is on hospice however licensee does not have hospice care plan which indicates the need which poses an immediate health, safety personal rights risk to R1.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Administrator will obtain a current hospice care plan which indicates the need for the full rails.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Oct 11, 2021

87555(b) General Food Service Requirements (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by: Based upon LPA's observation the facility did not have an adequate supply of fresh fruits and vegetables and canned goods.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Administrator will purchase food needed and provide a snapshot of food purchased.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(j) · Plan of correction due date: Oct 4, 2021

87705 Care of Persons with Dimentia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based upon LPA's observations, the alarm on all exit doors were not working. This poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Administrator will ensure alarms have been properly repaired. Administrator will send paperwork from the company (Vivint) stating the alarm has been properly repaired.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.311 · Plan of correction due date: Oct 4, 2021

1569.311 Carbon monoxide detectors required; inspection. Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility...This requirement is not met as evidenced by: Based on observation and interviews, licensee failed to ensure the facility had one or more carbon monoxide detectors at the facility which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Administrator will provide a receipt and a picture showing the devices have been installed within the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR80020(a) · Plan of correction due date: Sep 3, 2021

Fire Clearance Violations, including, but not limited to, over capacity, ambulatory status, inoperable smoke alarms, and inoperable fire alarm systems. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, This is not met as evidenced by observation and inteview the licensee did not comply with the regulation above by not ensuring the smoke detectors are operational which poses an immediate health,safety personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Adminstrator will notify the department in writing what steps were taken to clear this deficiency This is a zero tolearnce violation therefore a civil penalty in the amount of $500 has been issued. Civil penalty will continue to accrue in the amount of $100 per day until plan of correction has been submitted.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(b) · Plan of correction due date: Oct 4, 2021

87633(b) A current and complete hospice care plan shall be maintained ... for each hospice resident and include the following: This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above by not obtaining hospice plans for R1 and R2.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licenseevwill obtain a copy of the hopsice care plan fro both residents and submit copies to the LPA as POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87632(a) · Plan of correction due date: Oct 11, 2021

In order accept or retain terminally ill residents &... receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. This requirement was not met as evidenced by: Based on record review,the licensee did not comply with the section cited above by retaining 2 residents on hospice prior to obtaining an approved hospice waiver which poses an potential health, safety & personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee will Submit hospice care waiver request or exception to retain the two hospice residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Oct 11, 2021

87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not ensuring 5 out of 8 staff received first aid training which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee/Administrator will provide first aid training to all staff and submit copies of certificates/cards as POC.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.69(a) · Plan of correction due date: Oct 11, 2021

1569.69(a) Each residential care facility...shall ensure ... employee ... who assists residents with the self-administration of medications meets... training requirements: This requirement is not met as evidenced by: Upon review of the staff records, LPA observed staff has not completed the required medication trainnig.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee/Administrator will schedule vendorized medication training for all staff who assist residents with medication. Verification of scheduled training with the trainers credentials will need to be submitted by 10/01/2021 and verification of completed training will need to be submitted to LPA by 10/11/2021.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.696(a) · Plan of correction due date: Oct 11, 2021

1569.696(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care...the training requirements specified in .... The training shall include all of the following: This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not ensuring staff received the required training which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee/Administrator will need to schedule vendorized training for all staff. Verification of scheduled10/02/2021 with the trainers credentials will need to be submitted to LPA by 10/11/2021 and verification of completed training will need to be submitted to LPA by 10/11/2021.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.625(b) · Plan of correction due date: Oct 11, 2021

1569.625(b) Staff training; legislative findings; contents. (1) The department ...staff members ...who assist residents with personal activities of daily living to receive ... training. This training shall consist of 40 hours of training. ...(2) training requirements shall also include an additional 20 hours annually…. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not ensuring staff received the required training which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee/administrator will schedule vendorized training for all staff. Licensee/administrator will submit verification of scheduled training with the trainers credentials to LPA by 10/01/2021 and submit verification of completed training to LPA by 10/11/2021

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87405(a) · Plan of correction due date: Oct 11, 2021

87405(a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a certified administrator working which poses a potential health, safety, personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee/Administrator will need to notify the department in writing how this deficiency will be cleared.

From the deficiency page — Deficiency type: Type B · Section cited: HSC87468.1(a)(2) · Plan of correction due date: Oct 11, 2021

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above by not conducting routine symptom screening for resident,staff & visitors which poses an immediate health, safety, personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee/Administrator will begin screening all residents, staff and visitors. Licensee/Administrator will create a sign in sheet which includes COVID symptom questions and recorded tempereatures. Licensee will send a copy of the sign in sheet to LPA Spaeth.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Oct 11, 2021

87411(d)(5) (d) All personnel shall be given training... This training ...shall provide knowledge of and skill in the following,.. for the job assigned and ... job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not providing staff training on infection prevention, symptoms, transmission and PPE use by any individual trained in infection control which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee/Administrator will schedule training for all staff to be provided by and individual certified in infection control infection prevention, symptoms, transmission and PPE use, and all sections listed in the department LIC808 Mitigation Plan. Training will need to be scheduled within 24 hours and completed within 7 days. Licensee/Administrator will email LPA with the credentials of the trainer and the scheduled training date and submit verification of training once completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Oct 11, 2021

87411 (f) Personnel Requirements - General. 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. Based on interview, the licensee did not comply with the section cited above by not having qualified staff on the premises at nights resulting in absence of supervision for the 2 residents in care which poses an immediate health, safety personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: The Administrator agrees to provide CCL with a current, complete Personnel Report (LIC 500) This deficiency resulted in an absence of supervision which is a zero tolerance deficiency as per Health & Safety Code 1597.58 which states that an immediate Civil Penalty of $500 will be assessed at the time of the citation and an additional $100 per day until the deficiency is corrected.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(1) · Plan of correction due date: Oct 11, 2021

Residents in all residential care facilities shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff. This requirement was not met as evidenced by: Based on observation, interview, the licensee did not comply with the section by R1 by placing a baby monitor in resident room to monitor residents at night which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: The Administrator agrees to provide CCL with a current, complete and correct Personnel Report (LIC 500) that documents sufficient staffing and includes designated on-call staff with contact information and estimated response time to the facility in an emergency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(6) · Plan of correction due date: Oct 11, 2021

87465 (h)(6) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications ... is maintained for at least one year and includes… This requirement is not met as evidenced by:Based on interview and record review, the licensee did not comply with the section cited above by not completing/retaining centrally stored medication & destruction record for 2 out of 2 residents which poses a potential health, safety and personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee will complete centrally stored medication and destruction records for all residents and submit copies to the LPA as POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(b)(c)(d) · Plan of correction due date: Oct 11, 2021

Licensee is required to have PRN authorization letter on file signed by a physician to determine whether or not the residents can communicate the need and/or symptoms clearly for the as needed (PRN) medication. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not obtaining PRN authorization letters for 2 residents which poses a potential health,safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee will contact residents Physicians to obtain PRN authorization letters for all residents who they provide medication assistance to. Copies of the PRN authorization letters will need to be submitted as POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(b) · Plan of correction due date: Oct 8, 2021

87205 (b) Accountability of Licensee Governing Body-(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by: the licensee did not comply with the section cited above by not ensuring that the corporation remains active which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee will resolve the corporation status and ensure that it is active. Proof of resolution will need to be submitted as POC.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.605 · Plan of correction due date: Oct 11, 2021

Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests...This requirement was not met as evidenced by: Based on interview, the licensee did not comply with the section cited above as the failing to obtain/maintain liability insurance which poses a potential health, safety, personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee will review the health and safety code, obtain liability insurance as required by the health and safety code. Copy of the current liability insurance certificate will need to be submitted as POC.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87305(a) · Plan of correction due date: Oct 11, 2021

87305(a) Alterations to Existing Building or New Facilities Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Based on observations, the licensee did not comply with the section cited above by building unpermitted staff rooms in the garage which poses an immediate health, safety and personal rights risk to persons in care and staff.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee will notify the department in writing how this deficiency has been cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87207 · Plan of correction due date: Oct 11, 2021

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 is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by providing false/misleading statement regarding the designated facility administrator.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: The licensee will submit a written explanation why the false/misleading statements were made and what steps will be taken to prevent a repeat of this deficiency.