The Retreat

Type of visit: Required - 1 Year

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control domain, medication, and food review. LPA Flores met with Claudia Romero facility's manager and explained the reason for the visit. The facility is licensed to serve 9 non-ambulatory residents and has an approved Hospice Waiver for 2 residents. There is also a Dementia Program in place and a Food Service waiver to prepare food off premises and transport to the facility. The facility is a one single home with a kitchen, 5 private bedrooms 4 bathrooms; separate detached laundry area, an attached garage and backyard area. LPA Flores conducted a tour of the facility with Claudia Romero Manager and observed the following: Facility is clean and in good repair. Snacks were observed in kitchen's pantry and refrigerator. Cleaning supplies and sharps are kept in laundry room which is under lock. Medication is lock in kitchen's cabinet. Each resident bedroom was observed with sufficient lighting, the required furniture, and bedding supplies. Bedroom #3 has a covered fireplace. (4) resident bathrooms were observed, each with a skid mat, grab bars, and in working condition, water temperature was tested in each resident bathroom and tested between 107.2 - 113.7 which is within the required 105-120 degrees F. Living room area has a cover fireplace. Facility has a fire sprinkler system throughout the facility. Fire extinguisher is located across from kitchen entrance and in hallway outside bedroom #1 last checked on 2/28/22. Outdoor patio has a shaded sitting area. Facility is following infection control procedures. Signs were observed throughout the facility. Per administrator N95 mask fit testing has been schedule and will email the results of the staff that will provide direct care. LPA reviewed medication and files for 3 residents and files for 3 staff. A copy of liability insurance was requested. No deficiencies were noted during this visit. Exit interview was conducted with Claudia Romero Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 19, 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.

Allegation investigated: Staff is unable to provide appropriate care and supervision to a resident

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA conducted a telephone call with Aime Armenta and explained the reason for the visit over the phone due to COVID 19 precautions. The investigation consisted of the following: On 11/19/21 LPA Flores requested staff/resident roster,conducted a tour of the facility, no deficiencies were noted during the visit for physical plant. LPA interviewed resident #2(R2),#3(R3),#4(R4),#5(R5), reviewed files for Resident #1(R1), R3, and R5, requested copies of admission agreement, resident appraisal, physician's report, emergency and identification information, and appraisal needs and service plan for R1,R3,R5. LPA reviewed and requested copies of staff training for staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5). On 11/19/21 Administrator email LPA facility's plan of operation, incident report dated 11/19/21 and a copy of blank admission agreement. On 6/6/22 LPA Flores conducted a subsequent complaint investigation to deliver findings. (CONTINUED ON LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Staff is unable to provide appropriate care and supervision to a resident. It is alleged R1 suffers from Dementia and Alzheimer's and renders at facility which is unable to effectively house and care for resident. Interviews with residents revealed 4 out of 5 residents stated to be assisted with care as needed and staff assists resident with reaching out to the physician when needed. LPA was unable to interview R1 due to R1 being at the hospital at the time of the visit. Interviews with staff revealed 3 out of 3 staff interview stated R1 had some behaviors and facility seek medical care upon staff observing behaviors, staff also stated to receive annual training on dementia care. Documents reviewed for R1 revealed R1 was admitted to the facility on 9/29/21, R1's last physician's report was conducted on 7/26/21 and diagnose correlates with diagnosis mention in the allegation. Incident report dated 11/19/21 notes facility contacted paramedics on 11/16/21 to request medical care for R1 due to behaviors, however resident was not transported. On 11/17/21 Per primary physician's request administrator reached out to San Gabriel Medical Center Psychiatric Emergency Team (PET), who came to the facility and evaluated R1 and provided assistance with transferring R1 to receive proper care. Facility's plan of operation has a Dementia Special Care amendment in place, Admission's Agreement dated 9/19/21 provides information regarding Advertising Dementia Special Care Provisions. Staff training was reviewed and facility provided 8 hours of dementia training on 2/13/21. On 11/19/21 LPA Flores conducted a tour of the facility and observed facility follows dementia physical plant requirements according to Title 22 regulations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted with Ana Costa caregiver and a copy of this report was email to administrator.the state’s words, verbatim · CDSS document, Jun 6, 2022 · control 28-AS-20211117085850

Type of visit: Annual/Random

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control domain, medication, and food review. LPA Flores met with Claudia Romero facility's manager and explained the reason for the visit. The facility is licensed to serve 9 non-ambulatory residents and has an approved Hospice Waiver for 2 residents. There is also a Dementia Program in place and a Food Service waiver to prepare food off premises and transport to the facility. The facility is a one single home with a kitchen, 5 private bedrooms 4 bathrooms; separate detached laundry area, garage and backyard area. Facility has a fire sprinkler system throughout the facility, smoke/carbon monoxide detector in the dinning room that was tested and working. Fire extinguisher is located across from kitchen entrance. LPA Flores conducted a tour of the facility with and observed the following: Kitchen area: medication cabinet kept locked no sharps observed.. Chemical solutions locked in laundry area. Facility maintains snacks available in pantry and refrigerator. All (5) bedrooms have sufficient lighting, all required furniture and bedding. All resident's bathrooms have the required grab bars, mats, and water temperature was tested in bathroom #1 water temperature tested at 109.4 degrees F, bathroom #2 water temperature tested at 105.6 degrees F., bathroom #3 water temperature tested at 105.3 degrees F., and bathroom #4 water temperature tested at 105.2. Facility living room has a fireplace that is covered. Administrator certificate was observed for Claudia Romero #6002551740 expiration date 10/17/23.Facility is following COVID 19 recommendations by screening visitors, staff, and residents. Signs were observed. Hand washing signs posted near sinks, hand soap, and paper towels available. Staff have not been fit tested for N95s. PPE supplies were observed sufficient for 30 days. No deficiencies were given during this visit. Technical advisory was provided. Exit interview was conducted with Claudia Romero Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Linda Almaraz conducted an annual required visit at the above facility. LPA met with Supervisor Claudia Romero and Administrator Aimee Armenta later arrived during the inspection. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, food supply and Personal Protective Equipment (PPE). Facility has submitted a mitigation plan and is approved. LPA inspected all (5) bedrooms, (4) residents bathrooms, dining and living room. Facility has a main entry point for screening. Each bedroom has a chair, bed, linen, dresser, light, sufficient closet space and required furniture and equipment. All bathrooms were toured and the toilets, hand washing and showers are safe and sanitary. The common areas such as living room and dining area are clean and have the required furniture. Medications are centrally stored, locked along with the records. Resident Medication logs and medication were reviewed along with emergency contact information. Staff training records for COVID-19 were reviewed. Smoke alarm and Carbon monoxide detectors were inspected and seem to be operational. The facility has (3) fire extinguisher that are within the required operable range. The hot water temperature in bathroom #1 measured at 136.6 degrees F. Deficiencies cited under California Code of Regulations Title 22 An exit interview was conducted with the Administrator and a hardcopy was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, Aug 25, 2021