Indian Summer Place

Type of visit: POC

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Plan of Correction (POC) visit to ensure that deficiencies cited on 10/24/23 have been corrected. LPA met with Administrator Samantha Alex and explained the purpose for the visit. 87303(e)(2): on 10/13/23 LPA conducted the initial annual visit and observed water temperature in clients restrooms to be 128.6-129.5 degrees F, which was outside of the required range of 105-120 degrees F. During subsequent visit on 10/24/23 LPA observed water temperature in 1 out of 2 client restrooms to be at 127.2 degrees F, on both visits facility was cited Maintenance and Operation: 87303(e)(2). During todays visit LPA tested both client restrooms water temperature and they measured at 137.2 and 140.5 degrees F, Administrator lowered water temperature during visit. Civil penalty is being assessed. 87309(a): on 10/13/23 LPA conducted the initial annual visit and observed cleaning cleaning solutions in an unlocked cabinet under client bathroom sink, on subsequent visit 10/24/23 LPA observed knives to be stored in unlocked pantry and medication cabinet was unlocked within the unlocked kitchen. On both visits facility was cited Storage Space: 87309(a). During todays visit LPA toured facility, no cleaning solutions were found under clients restroom sinks, medicine cabinet was also observed and was locked. Kitchen was observed to have cleaning solutions stored under kitchen sink and were unlocked (administrator stated that the lock was lost), knives were observed in a separate cabinet and were also unlocked, during visit Administratror Samantha Alex locked both cleaning supply and knife storage cabinets. Civil penalty is being assessed. Exit Interview conducted and copy of the report and appeal right was provided to Administrator Samantha Alex. Administrator refused to sign LIC421FC's and 809.the state’s words, verbatim · CDSS document, Nov 3, 2023

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Tena Herrera conducted the continuation of the required annual inspection. LPA arrived unannounced and met with Samantha Alex (Administrator) and explained the purpose of today’s visit. The facility is licensed to serve 6 ambulatory elderly residents ages 60 and above. The facility is a single-story home located in a residential area. A tour of the facility includes: 2 living rooms, dining area, kitchen, laundry room with pantry, 4 bedrooms (2 client bedrooms, 1 administrators’ bedroom, 1 administrators daughters bedroom), 3 bathrooms (2 client and 1 Staff bathroom), back yard with required shaded area and outdoor furnishing. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. However, there was not an Infection Control Plan on file or accessible for review during initial (this is being cited on 809D). Operational Requirements: The facility has an approved fire clearance and outdoor activity area that is shaded and furnished for outdoor use. Staffing: Administrator Certificate and qualifications were not readily available during visit, this will be cited on 809D page. Personnel Records-Training: Staff has criminal record clearance, current first aid and CPR, and training. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility does not have the required Residential Care Facility for the Elderly (RCFE) Complaint Poster this will be cited on the 809D page. Resident Records-Incident Reports: Client files are kept in a secure location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. (Continued on 809-C) Physical Plant & Environment Safety: Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. During initial visit LPA observed bedding to be out of regulation, during subsequent visit bedding was still out of regulation with there being blanket and mattress pad only on one bed (missing bed sheets) [administrator stated resident does not wish to have sheets on bed] and blanket with sheet on other (missing mattress pad) [administrator stated that they use the plastic covering that comes with the mattress upon purchase as a mattress pad which is not compliant with regulation] this will be cited on 809D page. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested in resident bathroom during initial visit and was out of range (citation was issued) during subsequent visit water temperature was measured and was out of range at 127.2 degrees F the required range is 105-120 degrees F (new citation being issued today for water temperature). During subsequent visit cleaning supplies and toxins were centrally stored and inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and is fully charged. During initial visit it was stated that the kitchen remains locked to prevent residents from accessing medications and sharps that are stored within the kitchen, staff had indicated the only reason the kitchen was unlocked was because LPA was conducting tour, during subsequent visit LPA observed kitchen doors to be open and unlocked, LPA asked to see where sharps/knives were stored and they were stored in an unlocked cabinet as well as medication unlocked (citations will be issued on 809D). Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Health Related Service: Staff designated to administer medication has the proper training on file. Medication is properly labeled and are centrally stored in a cabinet and are in their original containers (during subsequent visit LPA observed medication cabinet to be unlocked, cited on 809D). During the initial visit, LPA reviewed 3 clients’ medication no issues were observed. Incidental Medical & Dental: Licensee assists in arranging medical and dental services to residents in care. (continued on 809-C) Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: There are currently no resident at this facility with special health needs. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the 809(D). Exit interview held and a copy of the report was provided to Administrator Samantha Alex.the state’s words, verbatim · CDSS document, Oct 24, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Samantha Alex (Administrator) and Henry Scott (staff) who assisted with the visit, the purpose for the visit was explained. FACILITY LICENSED TO SERVE ELDERLY RESIDENTS AGE 60 AND ABOVE. FIRE CLEARANCE APPROVED FOR 6 AMBULATORY RESIDENTS. During visit LPA toured the facility, reviewed client and staff records, reviewed client medications and facility files. There were 2 type A deficiencies observed during todays visit, one being hot water temperature and the other being disinfectants and cleaning supplies being accessible to clients in care. Details of these citations will be documented on the 809D page. Due to time constraints, LPA will continue this inspection at a later date. LPA will return to continue the required 1-year annual inspection. Exit Report held and a copy of this report and appeal rights were provided to Administrator Samantha Alex.the state’s words, verbatim · CDSS document, Oct 13, 2023

Allegation investigated: Staff are not answering facility phone. Staff abandoned resident.

**THIS IS A CORRECTED VERSION OF COMPLAINT REPORT DATED 8/17/23.** Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit to deliver findings on 08/17/23 regarding the above allegation(s). LPA Ramirez was met by Staff #1 (S1) and Administrator Samantha Alex and explained the purpose of the visit. S1 led LPA Ramirez on tour of facility. LPA Ramirez initiated Case Management-Deficiencies visit on 8/17/23 because of facility tour. The investigation consisted of the following: Initial complaint investigation was conducted on 4/18/23 by LPA Tena Herrera and needs further investigation was required. On 8/17/23, LPA Ramirez requested and obtained copies of Resident Roster, Staff #1-2 interviews (S1- S2), Resident #1 interviews (R1), Witness #1 – 2 Interviews (W1- W2), R1 Face sheet, R1 Discharge Summary/Comprehensive Assessment dated 7/24/23, Notice of Proposed Transfer/Discharge signed 7/19/23, Post Discharge Plan of Care signed 7/24/23, and other pertinent documents regarding this complaint. See 9099-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Staff are not answering facility phone- It is alleged that staff did not answer facility phone on or around 4/15/23. Two (2) out of two (2) staff interviewed deny this allegation. On 8/15/23 at 11:16 am, LPA Ramirez dialed facility phone number and was greeted by unknown staff. During today’s visit, LPA Ramirez observed facility phone to be operational. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff abandoned resident- It alleged staff abandoned R1 at hospital on or around 4/15/23. Two (2) out of two (2) staff interviewed deny this allegation. Interview with W2 revealed that W2 is R1 current physician and has been under W2’s care for the past 10 years. W2 revealed to LPA Ramirez that W2 ordered R1 to be sent to a rehabilitation facility on 4/15/23 and gave those order to hospital staff on 4/15/23. According to W2, R1 required a higher level of care at that time and could not go back to the facility. Admission Record from Coast Care Convalescent Care dated 7/12/23, indicates R1 was admitted into their facility on 4/15/23. Notice of Proposed Transfer/Discharge from Coast Care Convalescent Care dated 7/19/23, indicates R1 will be discharged back to Indian Summer Place on 7/24/23. LPA Ramirez interviewed and observed R1 in the facility during visit. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Samantha Alex. A copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 28-AS-20230414160419

Allegation investigated: Staff are not answering facility phone. Staff abandoned resident.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit to deliver findings on 08/17/23 regarding the above allegation(s). LPA Ramirez was met by Staff #1 (S1) and Administrator Samantha Alex and explained the purpose of the visit. S1 led LPA Ramirez on tour of facility. LPA Ramirez initiated Case Management-Deficiencies visit on 8/17/23 because of facility tour. The investigation consisted of the following: Initial complaint investigation was conducted on 4/18/23 by LPA Tena Herrera and needs further investigation was required. On 8/17/23, LPA Ramirez requested and obtained copies of Resident Roster, Staff #1-2 interviews (S1- S2), Resident #1 interviews (R1), Witness #1 – 2 Interviews (W1- W2), R1 Face sheet, R1 Discharge Summary/Comprehensive Assessment dated 7/24/23, Notice of Proposed Transfer/Discharge signed 7/19/23, Post Discharge Plan of Care signed 7/24/23, and other pertinent documents regarding this complaint. See 9099-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Staff are not answering facility phone- It is alleged that staff did not answer facility phone on or around 4/15/23. Two (2) out of two (2) staff interviewed deny this allegation. On 8/15/23 at 11:16 am, LPA Ramirez dialed facility phone number and was greeted by unknown staff. During today’s visit, LPA Ramirez observed facility phone to be operational. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff abandoned resident- It alleged staff abandoned R1 at hospital on or around 4/15/23. Two (2) out of two (2) staff interviewed deny this allegation. Interview with W2 revealed that W2 is R1 current physician and has been under W1’s care for the past 10 years. W1 revealed to LPA Ramirez that W1 ordered R1 be sent to a rehabilitation facility on 4/15/23 and gave those order to hospital staff on 4/15/23. According to W1, R1 required a higher level of care at that time and could not go back to facility. Admission Record from Coast Care Convalescent Care dated 7/12/23, indicates R1 was admitted into their facility on 4/15/23. Notice of Proposed Transfer/Discharge from Coast Care Convalescent Care dated 7/19/23, indicates R1 will be discharged back to Indian Summer Place on 7/24/23. LPA Ramirez interviewed and observed R1 in the facility during visit. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Samantha Alex. A copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 17, 2023 · control 28-AS-20230414160419

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 8/17/23 at 9 am, stemming from subsequent complaint investigation on 8/17/23. LPA Ramirez conducted tour of facility and records review in relation to complaint investigation. Deficiencies are being cited as a direct result of facility tour and observations made. Case Management-Deficiencies findings: · During medical record review of Resident #1 (R1) facility file, two (2) small insects that appeared to be “roaches” were observed crawling in between documents in R1’s file. Annual inspection conducted on 10/03/22, by LPA Long, resulted in deficiencies being cited. Facility was cited for violation of CCR- Maintenance and Operation 87303(a) “The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.” Plan of Correction (POC) indicated “Licensee shall obtain pest control services and provide proof to the department by POC due date of 10/17/22.” The facility submitted proof to clear POC on 10/16/22. Facility has failed maintain professional pest control services since 10/22. This is evidence by roaches still being observed in facility files and the facility’s failure to provide LPA Ramirez proof of continued professional pest control services at the facility. LPA Ramirez is issuing Civil Penalty Assessment for Repeat Violations in the amount of $250 for repeat violation within a 12 month period. Thereafter, a civil penalty of $100 a day will be assessed until the violation is corrected. Exit interview conducted with Administrator Samantha Alex. Deficiency and civil penalty were cited. A copy of this report and 809-D, LIC 421FC and appeals rights were provided.the state’s words, verbatim · CDSS document, Aug 17, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 31, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: 2 live small insects (roaches) were observed crawling in between R1's facility file. Facility was previously cited on 10/3/22 for same violation.the state’s words, verbatim · CDSS document, Aug 17, 2023

Plan of correction: Licensee will contract with professional pest control services. Licensee will submit contract to LPA Ramirez by 8/31/23. Licensee will maintain monthly professional pest control services until insects are eradicated from the facility.

Allegation investigated: Staff verbally abused residents in care. Staff physically abused residents in care.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Samantha Alex (Administrator) and explained the purpose of the visit. During today's visit, LPA obtained a copy of the Staff/Resident rosters, interviewed Residents #1 to # 4 in various locations of the facility and interviewed Staff #1 and #2 in the family room. In regards to the allegation: Staff verbally abused residents in care. Interviews with 4 of 4 Residents indicate Staff has never verbally abused them and they have never witnessed Staff verbally abusing other Residents. Interviews with 2 of 2 Staff indicate they have never verbally abused a Resident and have never witnessed Staff verbally abuse Residents. Continue to LIC9099C.... Unsubstantiated Based on LPA's record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC9099D. Immediate Civil Penalties of $500 for Staff #2 and $500 for Staff #3 documented on LIC421BG. Exit interview conducted with Samantha Alex (Administrator) and a copy of this report and appeal rights provided. In regards to the allegation: Staff physically abused residents in care. Interviews with 4 of 4 Residents indicate Staff has never physically abused them and they have never witnessed Staff physically abuse other Residents. Interviews with 2 of 2 Staff indicate they have never physically abused a Resident and have never witnessed Staff physically abuse Residents. Based on LPA's interviews, the investigation revealed: Although the allegations 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 allegations are unsubstantiated. Exit interview conducted with Samantha Alex (Administrator) and a copy of this report provided.the state’s words, verbatim · CDSS document, May 23, 2023 · control 28-AS-20230517124913

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 24, 2023

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Interviews with 4 of 4 Residents indicate Staff #2 is working in the facility. Interviews with 2 of 2 Staff also verified Staff #2 is working in the facility. Record review indicate Staff #2 has a criminal record clearance but is not associated to the facility.the state’s words, verbatim · CDSS document, May 23, 2023

Plan of correction: Licensee shall ensure Staff #2 is not working for the facility until Staff #2 in associated to the facility and provide proof to the department.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: May 24, 2023

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department.. This requirement is not met as evidenced by: 3 of 4 Residents interviewed indicate Staff #3 works in the facility and 2 of 2 Staff interviewed verified Staff #3 works at the facility. Record review indicate Staff #3 does not have a criminal record clearance and not associated to the facility.the state’s words, verbatim · CDSS document, May 23, 2023

Plan of correction: Licensee shall ensure Staff #3 is not working for the facility until Staff #3 obtained a criminal record clearance and associated to the facility and provide proof to the department.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Samantha Alex (Administrator) and explained the purpose of the visit. FACILITY LICENSED TO SERVE ELDERLY RESIDENTS AGE 60 AND ABOVE. FIRE CLEARANCE APPROVED FOR 6 AMBULATORY RESIDENTS. During today’s visit, LPA observed the following: Physical Plant and Environmental Safety: Sufficient lighting, non-skid maps in bathroom, comfortable temperature, Hot water temperature measured at 136.4 degree F in the hallway bathroom. LPA observed 2 live cockroaches in the Resident records. Operational Requirements: Facility has an approved fire clearance. Staffing: There is sufficient staff, the administrator is on the premises during normal business hours. Personnel Records - Training: Staff #1, #2 did not have current first aid/CPR training and LPA did not observed a health screening for Staff #2. Resident Records/Incident Reports: Admission agreement, medical assessment and appraisal observed. Resident Rights/Information: Complaint poster (PUB 475) posted on wall next to the garage entrance, resident's personal rights in file. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities, furnished areas is provided for relaxation of residents and entertaining friends and relatives. Food Services: Perishable foods are stored in covered containers, toxins are stored separate from foods, kitchen is kept clean. Resident with Special Health Needs: Hospice care plan is current, items that can constitute a danger is inaccessible to residents. Incidental Medical and Dental: Licensee provide assistance in meeting medical and dental needs for residents, all centrally stored medications is labeled and maintained in compliance with state and federal law. Per Title 22 Regulations, the deficiencies observed are documented on LIC809D. Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted and a copy of this report and appeal rights provided to Samantha Alex.the state’s words, verbatim · CDSS document, Oct 3, 2022

Allegation investigated: Lack of adequate supervision resulted in resident wandering from the facility on multiple occasions

Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegation listed above. LPA Spencer met with administrator Samantha Alex (Samieper Duque) and explained the purpose of today's visit. The investigation consisted of the following: The initial complaint investigation was conducted by LPA Juan Pablo Miramontes on 6/2/20 telephonically. A subsequent visit was conducted by LPA Spencer on 9/29/21 who interviewed the administrator, staff #1 (S1), and residents #1-2 (R1-R2). LPA took a tour of the physical plant and obtained documents for R6 including: admissions agreement, house rules, physician's report, medications list, hospital discharge papers, and caregiver's notes. During the course of the investigation, LPA interviewed R6's family member (F1) and attempted to reach R6's physician who could not be reached. On today's visit, R3-R4 were interviewed. R5 was not at the facility during the visit and R6 is a previous resident and could not be interviewed because R6 passed away. ***See LIC9099C for continuation of this narrative*** Unsubstantiated The investigation revealed the following: Lack of adequate supervision resulted in resident wandering from the facility on multiple occasions All staff and residents interviewed stated that there is adequate supervision at the facility at all times. Staff denied the allegation and indicated that the R6 was independent and physician's report allowed R6 to leave the facility unassisted. R1-R2 stated that they knew of one resident that would leave the facility and get picked up by police on several occasions due to appearing disoriented, but that all residents were allowed to leave when they wanted to. R3-R4 stated that they did not know of any residents that wandered away from the facility and that residents are allowed to come and go independently. F1 stated that R6 often wandered away from the facility and should have been placed in a locked facility because of R6's mental capabilities. A review of the house rules states that residents can leave the facility, but must sign in/out, and observe curfew at 9 p.m. A review of caregiver's notes reveals that R6 did leave the facility on multiple occasions without observing house rules. A review of R6's physician's report reveals that R6 is ambulatory and is able leave the facility unassisted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Oct 22, 2021 · control 28-AS-20200526142231

Allegation investigated: Lack of supervision resulting in resident to resident abuse Staff do not meet the minimum qualifications required by licensing Resident wandered away from the facility while in care

Licensing Program Analysts (LPAs) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with S-1 and discussed the pupose of today's visit. On 07/30/2020, LPA Miramontes initiated this investigation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA conducted this investigation telephonically with Samantha Alex (Facility Administrator). LPA obtained relevant documentation for this complaint investigation. During this investigation, LPA Irra interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. ***Refer to LIC 9099C for the continuation of this report*** Unsubstantiated Allegation: Lack of supervision resulting in resident to resident abuse. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Staff interviews revealed R-7 and R-8 would come in and out of this facility independently. Interviewed staff indicated Residents, at times, will get into verbal altercations and does not lead to physical contact. Per interviews, Staff are able to redirect Residents when this occurs. Interviewed staff indicated that they have not witnessed nor heard anyone stating that residents are being abused. Interviewed staff indicated that staff provide care and supervision to residents. Interviewed residents indicated there is staff providing care and supervision for residents. Interviewed residents indicated they have not witnessed any residents to resident abuse. Staff and Resident interviews do not corroborate this allegation. Allegation: Staff do not meet the minimum qualifications required by licensing During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Staff interviews revealed that staff are trained in resident rights, reporting requirements, supervision, resident abuse. Interviewed Residents were unable to provide an answer to this allegation as they do not know the minimum qualifications by licensing. Interviews do not corroborate this allegation. Allegation: Resident wandered away from the facility while in care During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Per staff interviews, R-7 and R-8 did not wonder out of this facility and indicated that R-7 and R-8 would go out in the community independently and return to this facility. Interviewed staff indicated residents do not wonder away from this facility. Interviewed residents indicated they have not witnessed nor heard of any residents wandering away from this facility. Interviewed residents indicated that residents whom leave the facility are independent and return to the facility. Per Staff interviews and record reviews, both R-7 and R-8, were independent and able to be out in the community unsupervised. Interviews and file reviews do not corroborate this allegation. 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 conducted, copy of this report and appeal rights were provided to S-1. Allegation: Staff failed to properly report incidents regarding residents. During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Resident #1 through Resident # 5 (R-1 through R-5). Resident #6 was asleep. Resident #7 and Resident #8 are no longer residing at this home and whereabouts are unknown. Staff interviews revealed that staff are trained in reporting special incidents. Interviewed staff indicated that it is responsibility to report special incidents to the Facility Administrator and in turn, the Facility Administrator reports the incidents to the appropriate entities. LPA was unable to obtain any special incidents for R-7 or R-8. Per staff interviews, R-8 indicated R-8 hit R-7 and staff interviewed all Residents. Per Staff interviews, no residents witnessed R-8 hitting R-7. Per file review, staff only had a hand written note on R-7’s and R-8’s file and was not reported to Licensing but was reported Long Term Care Ombudsman (LTCO). Per staff interviews, staff were under the impression that LTCO cross reports to Licensing. Per Staff interviews and record reviews, both R-7 and R-8, were independent and able to be out in the community unsupervised. Interviewed Residents were unable to provide an answer to this allegation as they do not know the special incident report guidelines. Staff interviews and file review corroborates this allegation. Based on observations, interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights were provided to S-1. NOTE: LPA was experiencing technical difficulties during today's visit.the state’s words, verbatim · CDSS document, Oct 11, 2021 · control 28-AS-20200721115641

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Oct 11, 2021

87211 Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but no 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 of any of the events specified in (A) through (D) below. 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. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.the state’s words, verbatim · CDSS document, Oct 11, 2021

Plan of correction: Administrator provided staff training on reporting requirements and provided proof of correction to LPA Irra during today's visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 97211(a)(1)(B) · Plan of correction due date: Oct 12, 2021

This is a continuation of the 87211(above). This standard is not met as evidence by: LPA was unable to obtain any special incidents for R-7 or R-8. Per staff interviews, R-8 indicated R-8 hit R-7 and staff interviewed all Residents. Per Staff interviews, no residents witnessed R-8 hitting R-7. Per file review, staff only had a written note on R-7's and R-8's file and was not reported to Licensing but was reported Long Term Care Ombudsman (LTCO). Per staff interviews, staff were under the impression that LTCO cross reports to Licensingthe state’s words, verbatim · CDSS document, Oct 11, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced annual required visit using the Infection Control domain. LPA met with Administrator, Samantha Alex, and explained the purpose of the visit. The facility is licensed for 6 ambulatory residents age 60 and over. There are currently 5 ambulatory residents at the home. LPA Chan toured the facility with the Administrator and inspected/observed the following: * There are 4 bedrooms and 3 bathrooms (3 bedrooms are for residents and 1 for the Administrator). Each bedroom is equipped with the required furniture. * There are 2 living rooms, a kitchen, and a spacious backyard with shaded area with a table and chairs. * Food supplies were observed for 2-day perishable and a week of non-perishable. * Some signs are posted regarding the Covid-19 (Coronavirus). * There are no items obstructing the entry or walkway. * Knives and disinfectants are inaccessible to residents. * Medication was reviewed for 3 residents and medications match the physician's orders. The following deficiencies were observed today: * The hot water temperature was measured at 134.2 degree F, which is over the required range of 105 – 120 degree F. * Staff #1 does not have fingerprint clearance nor associated to the facility. The deficiencies are documented on the LIC809D. An exit interview was conducted. A copy of this report, LIC809D, and the appeal rights were given to the Administrator.the state’s words, verbatim · CDSS document, Aug 19, 2021