4219 W. 162nd Street Home

Type of visit: Required - 1 Year

On 05/01/23, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Melanie Estepa and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 60 years and older, cleared for three (3) non-ambulatory residents. During the time of visit all three (3) residents were present, involved in their virtual day program. Structure The facility is a single-story home in a residential neighborhood. The facility has three (3) client rooms, two (2) bathrooms, kitchen, dining room, living room, office space, and a detached garage, and laundry/storage area. Physical Plant LPA walked the outside of the facility. LPA observed a shaded patio with a table and chairs available for resident use. Additionally, there is a shaded chair swing. The front and back are landscaped and well maintained. LPA did not observe any bodies of water. All walkways were clean, clear, and free of obstructions, hazards, and debris. All gates and exits are easily accessible. Bedrooms All bedrooms were toured. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand with lamp, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms. Bathrooms Both bathrooms were toured and meet Tittle 22 regulations. LPA observed the bathrooms to be clean and free of mold or mildew. The toilet, faucets and showers are in good working repair. The safety grab bars are secured. LPA observed a nonskid mat and chair in the shower. The water temperature measured 116.9- and 117.6-degrees Fahrenheit. Kitchen LPA toured the kitchen and found it to be clean and sanitary. All appliances are in good working repair. LPA observed an ample supply of cutleries, pots, and pans to be in good repair. LPA observed a three (3) day supply of perishable and a seven (7) day supply of nonperishable food. Additionally, in the garage is an extra supply of canned goods, multiple 5-gallon bottles of water, and a refrigerator with food. Water temperature measured 117.9 degrees Fahrenheit. Knives and other sharps are secured in a locked drawer in the kitchen. Linens & Hygiene Extra linens were stored in each client’s individual closets. LPA observed towels and personal care products were stored on shelves and in a cabinet in the bathroom. An additional supply of hygiene products are stored in a cabinet in the laundry/storage room. Cleaning Supplies All cleaning supplies, toxins, and equipment are stored in the hall closet. LPA observed an additional, ample supply of cleaning products secured and locked in the detached laundry/storage room. Safety LPA observed all exits clearly marked. A facility sketch with shut off valves marked was posted at the entrance. The smoke and carbon monoxide detectors were tested and in good working repair. There is a fully charged fire extinguisher mounted in the kitchen last serviced on 07/03/22. The last emergency drill was conducted on 04/05/23. LPA tested the working landline telephone. The First Aid kit was inspected and contained all required items with the manual. LPA observed all required signs and numbers posted. Egress systems on all doors were in good working order. There are no firearms or ammunition stored on the premises. File Review LPA reviewed all resident files and found they contained the required documents. LPA reviewed five (5) staff files and found they contained the required documents, training, and certification. LPA reviewed the three (3) residents P & I for the past year. LPA reviewed the surety bond. LPA reviewed the training logs for staff. LPA received a copy of the Liability Insurance. Interviews LPA interviewed two (2) residents, one (1) was sleeping. All residents interviewed were happy and felt they are treated well. LPA interviewed the three (3) staff present. All staff were able to explain the facilities process and procedures and the personal rights of clients. Medications Centrally stored medications were observed stored in their originally received containers. All medications were secured in a locked drawer and are inaccessible to residents in care. LPA reviewed the MARs and medications for each resident. Infection Control During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log. PPE supplies are readily available to staff, and an additional 90-day supply of PPE are stored in the garage. LPA observed a sufficient paper, cleaning, and disinfecting supplies in both the locked hall closet and laundry/storage area. No deficiencies were cited. An exit interview was conducted with Melanie Estepa and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 1, 2023

Type of visit: Required - 1 Year

On November 18, 2022, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit with a primary focus on Infection Control measures using the CARE Inspection Tools. LPA met with Melanie Estepa and explained the purpose of the visit. The facility is licensed to serve elderly developmentally disabled residents ages 60 years and older, cleared for three (3) non-ambulatory residents. Currently, there are three residents and 3 staff present in the home during today’s visit. Structure The facility is a single story home in a residential neighborhood. The facility has three (3) client rooms, two (2) bathrooms, kitchen, dining room, living room, office space, and a detached garage. Physical Plant LPA walked the outside of the facility. In the back there are table and chairs available for use. LPA did not observe any bodies of water. All walkways were clear, free of obstructions and debris. Bedrooms All bedrooms have the required furniture. Each room contained a bed, dresser(s), nightstand, closet space, and chair(s). There was adequate lighting in the bedroom. Bathrooms Both bathrooms were inspected and meet regulations. The toilet, sink and showers are in good working order. The grab bars were secured, and a nonskid mat and chair were available in the shower. The water temperature measured 118.3-119.1 degrees Fahrenheit. Kitchen All appliances are in good working condition. LPA observed three (3) day supply of perishable and seven (7) day supply of nonperishable food. Water temperature measured 119.1 degrees Fahrenheit. Knives are locked in a drawer in the kitchen. Linens & Hygiene Extra linens were stored in each client’s individual closets. Also towels and personal products (diapers, mats) were stored in client’s closets. Additional hygiene products were stored in a cabinet in the bathroom. Cleaning Supplies All cleaning supplies and additional cleaning equipment were stored in the hall closet. Safety The smoke/carbon monoxide detectors were in good working order. There is a full charged fire extinguisher in the kitchen. The First Aid kit was inspected and contained all required items with the manual. The last emergency drill the facility had was on 11/3/22. Egress systems on all doors were in good working order. File Review LPA reviewed all resident files. All files contained the required documents. Three staff files were reviewed and contained the required and up to date documents. Medications Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. LPA reviewed the MARs and medications for each resident. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 90-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed. LPA reviewed the Liability Insurance and it is good till 8/23/23. No deficiencies were cited. Exit interview was conducted with Melanie Estepa.the state’s words, verbatim · CDSS document, Nov 18, 2022

Allegation investigated: Staff inappropriately handle residents in a rough manner Staff yells to residents in care.

Licensing Program Analyst (LPA) Jey Cardenas conducted an initial 10- day complaint visit to the above facility to investigate allegations listed above. Upon arrival at the facility LPA meet with Lead caregiver, Usi. LPA explained the reason for today’s visit and conducted a Covid-19 risk assessment, based on the assessment facility is clear of covid-19 infection. The investigation consisted of following: During today’s visit on 7/14/22 LPA Cardenas toured plant, requested/ resident roaster, reviewed three (3) resident files and Staff#3 (S3) file. Interviewed Administrator, Melanie Estapa and S3 via telephone, Staff#1-Staff#2 (S1-S2) were interviewed in person, attempted to interview Residente#1 – Resident#3 (R1-R3), attempted to interview S5-S8 via telephone, but were unavailable. Attempted to interview Regional Center Service Coordinator (SC). Complaint received alleging that since April2022 S3 has been observed yelling at and handling residents in a rough manner. Allegedly there has been multiple incidents that have happened since then, Unsubstantiated (continued pg2) however allegations were recently reported near the end of June2022. Specific dates of incidents were not provided. Per record review: Unusual Incident Report (UIR); on 6/29/22 Licensee Greg Andres received a call from staff reporting grievance, alleging that S3 yells at and handles residents in a rough manner. It is also noted that S3 used personal phone during shift to take a picture of S4 sleeping on the job. Per training records S3 received zero tolerance/ Abuse/ SIR Reporting training on a yearly basis from 2019-2022. Per facility internal notes reviewed; LPA didn’t find documentation with indication of staff handling residents in a rough manner, nor yelling. Regarding allegation- Staff inappropriately handle residents in a rough manner. On 7/14/22 LPA interviewed administrator Melanie Estapa who indicates that on 6/29/2022 S4 reported S3 for handling residents in a rough manner and yelling. These allegations were investigated by facility; all staff were interviewed and none of staff reported witnessing S3 or any other staff handling residents in a rough manner nor yelling at residents. Melanie has observed S3’s interactions with residents and staff handles residents well. These allegations are an isolated incident and have never been reported in the past. Residents families have not reported any concerns regarding staff care. All staff receive yearly zero tolerance/ abuse/ reporting in-service training. In addition, during the monthly staff meetings these items are also reviewed. On 7/14/22 LPA interviewed S1-S3 who denied yelling and handling residents roughly. All three staff indicate that they have not witnessed other staff handle residents in a rough manner. All three (3) resident families are involved and none of the families have complained nor have concerns regarding residents being mishandled, staff treat residents with respect and dignity. On 7/14/22 LPA Cardenas attempted to interview there (3) out of there (3) residents; however due to cognitive impairment a statement couldn’t be obtained. On 7/14/22 LPA Cardenas contacted three (3) out of three (3) witnesses; however, was only able to speak with one (1) witness (W1). W1 indicates staying in touch with resident via phone. About two years ago W1 visited the facility in person and observed staff interaction with residents; residents are handled well. W1 has no concerns about the facility staff care, “care is great.” Staff working there are dedicated. Regarding allegation- Staff yells at residents in care. During interview with administrator Melanie Estapa, she indicated never witnessing staff yell at residents, not obtaining a report about staff yelling at residents. S3 has a loud voice and that may have been factor for the allegation regarding yelling. None of the staff have (continued pg3) reported staff yelling at residents. During interview with S1-S3 they denied yelling at residents. They indicated that they have not witnessed staff yelling at residents. None of their coworkers have reported witnessing another staff yelling at residents. During attempted interview with R1-R3, LPA was unable to obtain statement. During interview with W1, witnessed reported having no concerns. Per observations made- LPA observed residents were well groomed, cleaned and there were no marking's on body that would indicate residents are being handled roughly. Based on LPA’s interviews, record reviews and observation LPA did not find sufficient evidence to support the allegations, Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report to be provided to facility representative.the state’s words, verbatim · CDSS document, Jul 14, 2022 · control 11-AS-20220712154336