Lily of the Valley

Type of visit: Required - 1 Year

On 09/14/23 Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by staff and explained the reason for the visit. Shortly after, LPA met with Rodolfo Espino. A tour of the physical plant was conducted at 10:15AM. The facility has 6 bedrooms. Bedrooms: Five (5) bedrooms designated for residents' use and (1) bedroom designated for staff. All bedrooms were clean, properly furnished and had sufficient lighting. Common Areas: This includes the living room dining areas were appropriately furnished and lighting was adequate. LPA observed medication cabinet to be locked and inaccessible to residents. The living room has a television and comfortable furniture. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed that sharp objects were stored in locked drawers and cabinets. LPA observed fully stocked first aid kit in the kitchen the fire extinguisher purchased date 08/24/23. LPA found a sufficient amount of perishable and non-perishable food at the facility. Temperature: Facility maintains a comfortable temperature of 80 degrees Fahrenheit. Bathrooms: There were three (3) bathrooms in the facility. One (1) bathroom in hallway which is the main and two (2) bathrooms in the private bedrooms. All bathrooms were clean, properly supplied and had functional fixtures. All chemical cleaners were locked under the sink cabinet. Laundry Area: located through the kitchen. Appliances observed to be in good repair. All cabinets were locked and thus laundry detergents were inaccessible to residents. Backyard Area: There is a clean covered shaded area in the back yard and there is a pool which has a gate and is kept locked and inaccessible to residents in care. LPA also observed another room outside in the backyard next to the pool that has a hospital bed and a private bathroom. This room was not indicated on the facility sketch during the application process, which posed a potential health and safety issue for residents in care.Garage: LPA observed the garage been converted to a room with private bathroom. Review of facility sketch does not indicate that there is a room created in the garage. Interview with administrator revealed that the room was built during COVID for staff for isolation in case of contact. During records review LPA observed Tramadol medication over the number that stated on the container. Interview with administrator revealed that Administrator has transferred old Tramadol medication to the new container. Exit interview conducted and a copy of the report and appeal rights were provided. Deficiency was cited on 809D.the state’s words, verbatim · CDSS document, Sep 14, 2023

Type of visit: Required - 1 Year

On 8/26/22 at 10:10 a.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff member. LPA observed covid-19 signage, hand sanitizer and a visitor sign in log. Staff did not screen LPA for infection control protocols. Staff contacted the Administrator and LPA met with the Administrators/Licensees at 11:00 a.m. The purpose of the visit was explained, and an entrance interview was conducted. LPA initiated a physical plant tour at 10:45 a.m. This is a six (6) bedroom, three (3) bathroom Residential Care Facility for the Elderly. LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area and has a date of purchase of 6/18/2022. Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a comfortable temperature of 79 degrees Fahrenheit. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Extra towels and linens were readily available. There is a clean covered shaded area in the back yard and there is a pool which has a gate and is kept locked and inaccessible to residents in care. Deficiencies issued per CA Code of Regulations Title 22 during today’s visit. Report was signed and delivered by Administrator/Licensee and an exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 26, 2022

Allegation investigated: Resident sustained injury while in care resulting in death.

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to close out the investigation regarding the above allegation. Entrance interview conducted. On 10-05-2021, a complaint was received by the Woodland Hills South Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s, Investigations Branch and investigated by Robert Kujawa. The department initiated the 10 day visit 10/6/21. The LPA toured the home and reviewed documentation. The investigator conducted interviews with staff on 2/14/22. Witnesses were interviewed on 3/14/22 and resident file reviews were conducted 08-18-2020. Medical documentation was subpoenaed 11/18/21, received and reviewed on 1/13/22. Unsubstantiated It was reported that on or around 9/24/21, Resident 1 (R1) was transported and admitted to the hospital with several bleeding wounds. No other specific details provided regarding how R1 obtained these wounds. R1 passed away on 9/27/21. Interviews with the licensee, R1’s primary physician and R1’s family gave no indication that R1 sustained an injury, resulting in death due to facility neglect. Resident 2 (R2) was also interviewed and express no complaints or concerns regarding the care and supervision provided, stating satisfaction with facility services. Review of medical records reveal that R1’s cause of death was due to pneumonia. R1 was taken to the hospital for shortness of breath with signs of fungal infection on the upper back that was treated by the doctor. A further review of the physician’s notes indicate that the doctor had been treating R1 for 20 years. R1 has had recurrent skin condition of the skin, chest wall and back. R1 had been under the doctor’s treatment for both antifungal and oval med diffusion. Based on the information obtained through interviews and record review, there wasn’t enough evidence to corroborate the allegation of resident sustaining injury resulting in death. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, May 26, 2022 · control 31-AS-20211005123059

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Angelica Arambulo conducted a case management visit in conjunction with complaint # 31-AS-20211005123059. During the review of documents of the complaint it was discovered that the following documents are not updated or submitted to licensing. Register of residents is not done. Staff schedule is not done reporting requirements of hospitalization's or death not submitted. The facility is cleared for only 1 hospice resident and there are 2. Mr. Rudy Espino states he is still working on this. Resident PRN medication was not documented and administrator does no recall what it was for. The stored medication and destruct log has not been updated since April 2021. Upon entry the staff does not wear a mask. Screening is just your temperature. No questions asked at entry. Any citation which has not been issued during todays visit shall be cited on LPA next visit. Citations issued, appeal rights given, exit interview conducted. The report shall be emailed to administrator.the state’s words, verbatim · CDSS document, Oct 6, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211A(1)(a) · Plan of correction due date: Oct 14, 2021

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by record review and administrator admission that he never completes incident reports.the state’s words, verbatim · CDSS document, Oct 6, 2021

Plan of correction: The administrator shall submit a declaration that he has reviewed the required of this section and shall submit a complete incident on the residents hospitailzations and death. Failure to submit the POC for this citation may lead to civil penalities if not corrected.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(3) · Plan of correction due date: Oct 14, 2021

Administrator Qualifications: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidence by records review and administrator admission to not follow requirements of maintaining records. Such as reporting requirements. each time a resident was hospitalized.the state’s words, verbatim · CDSS document, Oct 6, 2021

Plan of correction: The administrator shall submit a declaration that he has reviewed and understands the required section 87405 on administrator qualifications. The declaration shall be submitted to LPA Arambulo by the due date to clear this citation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Oct 14, 2021

Incidental Medical and Dental (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement has not been met as evidence by The administrator could not locate the PRN for resident #1 antibiotics. Medication was no longer available.the state’s words, verbatim · CDSS document, Oct 6, 2021

Plan of correction: The administrator shall obtain a copy of the original prescription for the residents antibiotics and submit to LPA along with a declaration that he has reviewed section 87465 regarding medications. This deficiency shall only be cleared once corrections are submitted Failure to do so may be subjected to assessment of civil penalties.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87508 · Plan of correction due date: Oct 14, 2021

Register of Residents (a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: (b) Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement has not been met as evidence by a review of facility documents. The administrator did not know what the register was and did not have any updated documents.the state’s words, verbatim · CDSS document, Oct 6, 2021

Plan of correction: The administrator shall review section 87508 and submit a declaration that he has read and reviewed and understands this requirement. An LIC9020 shall be submitted to LPA and each time there is a change in census the administrator shall update this form.