Compassionate Elderly Care Management Systems

Allegation investigated: Staff left resident in wet diaper for an extended period of time Facility refused to accept resident back from hospital

At 10:30 am. on 09/26/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the Administrator and disclosed the reason for the visit. To investigate the allegations above, LPA interviewed three (03) out of three (03) staff and two (02) out of four (04) residents present at the facility today between 11:00 a.m. and 12:30 p.m. and reviewed pertinent records at 1:00 p.m. Records included but were not limited to the staff list, resident list, face sheet, medication schedule, discharge evaluation, insurance verification form, and medical assessment Regarding the allegation “Staff left resident in wet diaper for an extended period of time” it was alleged that Resident #1 (R1) arrived at the hospital with a soiled diaper. Interview with the Administrator today at 11:00 a.m. revealed an ambulance came to pick up R1 at approximately 10:45 a.m. on 09/20/2023. Unsubstantiated The Administrator had the paramedics wait while she provided R1 with a clean diaper, and the ambulance left at approximately 11:00 a.m. Staff interviews at 11:45 a.m. and 12:00 p.m. today confirmed R1 was changed at least 3 times per day or as needed, and R1 was never left in a soiled diaper at the facility. Based on interviews, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility refused to accept resident back from hospital” it was alleged the facility did not readmit R1 to the facility after R1 was admitted to the hospital. Interview with the Administrator at 11:00 a.m. today revealed R1 was hospitalized on 09/20/2023 for general weakness and overall change in condition. The Administrator noted the facility was able to provide care and supervision to R1 based on observations and records reviewed during the preplacement appraisal process. R1 could not be readmitted due to their change of condition, which made them no longer suitable for the facility. It was determined R1 needed a higher level of care. Staff interviews at 11:45 a.m. and 12:00 p.m. today confirmed R1 exhibited aggressive behaviors which were not documented in their records and were verbally confirmed after admission. Record review at 1:00 p.m. today of R1’s medical assessment and discharge evaluation revealed R1 had some cognitive impairment and physical challenges, but the documents did not mention the behaviors which were exhibited at the facility. Based on interviews and record review, the facility was not able to accommodate R1’s needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time, and the insufficient preplacement appraisal is addressed on a separate case management report. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 26, 2023 · control 31-AS-20230922112528

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility to check on Residents #1 & #2 (R1 & R2) to ensure that they are safe and well. LPA conducted physical plant tour at 10:15 AM and conducted interviewed with R1 & R2 and administrator between 10:30 to 11:00 AM, LPA interview with R1 and R2 revealed that they are doing fine at the facility at this time. There is no health and safety concern observed during this visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Nov 4, 2022

Allegation investigated: Staff did not follow protocols to prevent the spread of COVID-19

LPA Spaeth unannounced visit and was greeted by caregiver. LPA stated the purpose of the visit was to conduct a complaint investigation which states staff did not follow protocols to prevent the spread of COVID 19. LPA stated that it was observed by an outside Los Angeles County reporting party that the reporting party was not screened by caregiver when entered the facility on 9/09/2022. Reporting party stated temperature was not taken and reporting party had to prompt caregiver to conduct this procedure. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency is cited (refer to LIC 9099-D). Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to caregiver. . Substantiatedthe state’s words, verbatim · CDSS document, Sep 29, 2022 · control 31-AS-20220926161752

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(c)(f) · Plan of correction due date: Sep 29, 2022

87470 Infection Control Requirements (c) An Infection Control Plan shall be developed . (f) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement was not met as evidenced by: Based upon LPA's interview of the reporting party, the facility staff did not record the reporting party's temperature until prompted by the reporting party, which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2022

Plan of correction: Upon entering the facility, LPA's temperature was taken and COVID questions recorded at the sign in station.

Type of visit: Required - 1 Year

LPA Spaeth an unannounced visit and was greeted by caregiver. LPA observed caregiver was wearing a mask. LPA's temperature was taken and COVID questions. LPA observed the sign in station at the entrance of the facility. Caregiver stated there are two residents living in the facility. LPA observed comfortable seating in the family room and a dining room table within the dining room section of the facility. LPA observed the resident bedrooms contained bed, linens, night stand, and lamp. LPA observed the outside area contained comfortable seating and the side gate leading to the front yard was not locked. LPA observed the residents' medications were locked in a hallway closet. The closet also contained additional PPE. There are two bathrooms in the facility and both contained slip resistant mat, hand soap, paper towels, and a trash can. The smoke detectors were tested at 11:00 am and were properly working. Also, LPA observed fresh linens in a hallway closet. Upon entering the kitchen, LPA observed a seven day supply of canned goods and a two-day supply of fresh vegetables and fruits in the refrigerator. The freezer section of the refrigerator contained frozen meats. LPA observed hand soap at the kitchen sink. LPA observed the kitchen cabinet beneath the sink was not locked. The cleaning supplies were located in the cabinet. LPA observed the cabinets above the washer and dryer were not locked which contained the laundry detergent. A deficiency was observed and is hereby cited. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency is cited (refer to LIC 9099-D). Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to caregiver.the state’s words, verbatim · CDSS document, Sep 29, 2022

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Sep 29, 2022

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: Based on observations made during LPA's annual visit, the cleaning supplies underneath the kitchen sink and washing detergent in the laundry room were not locked which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2022

Allegation investigated: Staff left resident unsupervised during medical appointment. Staff provided expired medication to resident. Staff not meeting resident's medical needs. Staff provided resident with another resident's prescribed medication.

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegations above. LPA met with the administrator and explained the reason for this visit. Staff left resident unsupervised during medical appointment. It is alleged that facility left resident #1 (R1) unsupervised during a medical appointment. Initial visit was conducted on 7/9/21. During this visit LPA was unable to interview R1 due to R1 passing away approximately six months ago. LPA interviewed the administrator regarding this allegation from 10:45-11:15 am. LPA reviewed R1's facility file which included R1's physician report and needs and service plan from 11:15-12:15pm. LPA also reviewed copies of R1's hospital record. Information from R1's physician report and needs and service plan indicate R1 was able to leave the facility unassisted and handle their own medications. Interview with facility staff revealed that staff would drive R1 to their medical appointments and but would not go in with R1. Based on the information obtained through interview and documentation this allegation is deemed Unsubstantiated at this time. Unsubstantiated Staff provided expired medication to resident. It is alleged that when R1 went to their physician appointment that they had an inhaler that was empty and had expired. LPA was unable to interview R1 to them passing away prior to this visit. LPA reviewed R1's facility file which indicated that R1 handled their own medication and did not receive assistance with incidental health and medical care. LPA interviewed the administrator regarding this allegation. Based on the information obtained through record review and interview this allegation is deemed Unsubstantiated at this time. Staff not meeting resident's needs. It is alleged that R1's feet were in poor condition and that R1 was not being bathed enough. LPA conducted an interview with the administrator regarding this allegation. LPA also reviewed R1's facility file which included R1's physician report and pre-placement appraisal. LPA also received copies of R1's hospital records. Information from R1's records indicate R1 did not receive any assistance with bathing or grooming. Based on the information obtained through record review this allegation is deemed Unsubstantiated at this time. Staff provided resident with another resident's prescribed medication. It is alleged that R1 was provided with R2's medication when they went to a physician's visit. LPA was unable to interview R1 regarding this allegation due to R1 passing away. LPA interviewed R2 regarding this allegation and R2 could not recall anything about it. LPA interviewed the administrator who stated they were not aware of anything like that happening. He stated both of them handled their own medications and there had been issues in the past with residents trying to share medications and that he had been in touch with licensing regarding that issue. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Aug 2, 2022 · control 31-AS-20210702142639

Allegation investigated: Adequate food service is not provided to residents Staff does not follow food menu for residents Staff not meeting residents dietary needs

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to investigate the allegation above. LPA met with the administrator and explained the reason for this visit. LPA conducted a physical plant tour to ensure no immediate health and safety issues and none were noted during the tour. Adequate food service is not provided to residents It is alleged that the food served is not of good quality. Previous visit was conducted on 5/27/22 where interviews were conducted. During today's visit LPA interviewed staff from 10:15-10:30 regarding the allegation. LPA checked the food supply of the facility from 10-10:15am. LPA observed there to be a sufficient amount of perishable food and non perishable food. LPA observed there to be a sufficient amount of fruits and vegetables. LPA interviewed residents regarding this allegation. Information from interviews revealed that food service is fine. Administrator had a telephone call with Licensing Program Manager (LPM) Cassandra Harris on 7/12/22 regarding issues the facility was having with R1 regarding food service. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time. Unsubstantiated Staff does not follow food menu for residents It is alleged that the facility only has a good dinner menu but does not follow what is on the menu. LPA conducted interviews with residents and staff regarding this allegation. According to Title 22 regulations facility only has to have a sample menu and LPA was able to view the sample menu. Interviews with residents revealed that for the most part the menu is followed but it can change but the food is still of good quality. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Staff not meeting residents dietary needs It is alleged that staff is not serving fruits or vegetables. LPA conducted interviews with residents and staff regarding this allegation. During the physical plant tour LPA checked the food supply and observed there to be a sufficient amount of fruits and vegetables. Based on the information obtained through interviews and observation this allegation is deemed Unsubstantiated at this time. Exit Interview conducted. Copy of report issued.the state’s words, verbatim · CDSS document, Aug 2, 2022 · control 31-AS-20220523171448

Type of visit: Case Management - Deficiencies

LPA Spaeth conducted an unannounced visit to investigate Complaint #31-AS-20220523171448. Upon arriving at the facility at 10:00 am, LPA observed the caregiver who greeted LPA at the front door was not wearing a mask. LPA and Caregiver toured the facility from 11:40 until 12:00 noon. At 11:40 am, LPA and caregiver entered the kitchen. LPA asked the location of the knives and cleaning supplies in the kitchen. LPA observed the caregiver open the cabinet below the kitchen sink but noticed the lock that was placed on the cabinet was not locked. Caregiver opened the cabinet and LPA observed the cleaning supplies and knives were in the cabinet.the state’s words, verbatim · CDSS document, May 27, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(5)(b)(2) · Plan of correction due date: Jun 3, 2022

All staff and volunteers providing direct care to a resident....shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents...This requirement was not met as evidenced by: Upon entering the facility, LPA observed staff member was not wearing a mask which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2022

Plan of correction: Administrator will conduct training for staff regarding infection control guidelines. Administrator will provide to LPA signature of staff members who participated in the training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87309(a) · Plan of correction due date: May 27, 2022

Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by; LPA observed the cleaning supplies were stored underneath the sink but the cabinet was not locked which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2022

Plan of correction: At 12:25 pm, LPA observed caregiver locked the cabinet. LPA stated staff need to ensure the cabinet is locked at all times.

Type of visit: Required - 1 Year

LPA Spaeth conducted an unannounced annual visit to the facility and arrived at 10:30 am. LPA was greeted by Charles Oyibu, staff member who was wearing a mask and requested LPA sign in. Staff member recorded LPA's temperature. LPA explained the purpose of the visit is to conduct a annual visit to the facility. Staff member escorted LPA throughout the facility and LPA observed the COVID sign at the front door, the sign in station with thermometer, sign in sheet, and hand sanitizer. LPA was then escorted to the kitchen and observed the knives and cleaning supplies were locked underneath the sink. LPA observed an adequate supply of fresh vegetables and fruits in the refrigerator along with frozen meats. The pantry was stocked with canned goods. LPA was then escorted to the hallway and observed the medications were securely locked in a cabinet. LPA observed the bathroom which contained wash your hands sign, hand soap, paper towels and a trash can. LPA observed a 90 day supply of PPE which included masks, gloves, hand sanitizer and other items which were stored in a hallway closet. LPA observed the linens were also stored within the hallway closet. LPA Spaeth observed a person mopping the floor and asked Staff member to identify the person in the facility. Staff member stated is a family member visiting the Administrator. Pursuant to Title 22 California Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and a copy of the report along with the appeal rights provided to licensee.the state’s words, verbatim · CDSS document, Sep 1, 2021

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Sep 3, 2021

87355 Criminal Record Clearance (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement is not met as evidenced by: Based on LPA Spaeth observing a individual in the facility mopping the floor, LPA was told the person was not a staff member and has been visiting for the past three weeks.the state’s words, verbatim · CDSS document, Sep 1, 2021