Glendale Garden Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was allowed entry by Violeta Necesito (Caregiver) and Jorgen Deleon (Caregiver) and explained the purpose of today's visit. Administrator, Irene Deanon arrived at 10:30am and assisted LPA with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and was reviewed. Facility has not developed and submitted the infection control plan to CCLD. Administrator agreed to develop and submit the Infection Control Plan to CCL. Facility has COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Staff are adhering to infection control requirements. Operational Requirements: Administrator cannot find and provide the plan of operation to LPA for review. Liability Insurance policy (policy # 00105792-3) in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 7/29/2024. There was no proof of Fire and Disaster Drill which was to be conducted on a quarterly basis. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed to serve 6 non-ambulatory residents ages 60 and over, of which six (6) may be bedridden. Hospice waiver for 6 was approved. Current census is five (5) non ambulatory, one (1) ambulatory, two (2) are under hospice care and one (1) is bedridden. Home consists of five (5) resident bedrooms, one (1) office room, three (3) bathrooms, living room, dining room, staff lounge area, kitchen, backyard, and a detached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has two (2) fire extinguishers which were last inspected on 5/04/2023. Cleaning supplies and toxic substances are inaccessible to residents. At 10:05am, hot water temperature readings measured 113.9 deg F in bathroom #1, 114.9 deg F in bathroom #2 and 116.4 in bathroom #3 which are within the required 105-120 degrees Fahrenheit. ***CONTINUED ON LIC 809-C** Staffing: A total of eight (8) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Administrator certificate expired on 6/11/2023. However, Administrator stated that she submitted her renewal in May 2023 and finished all the required courses. Administrator awaits for the actual Administrator certificate. Three (3) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training. Resident Records-Incident Reports: Three (3) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full bed rails were reviewed in five (5) residents files. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. However, Administrator did not have planned activities in place or posted in the facility. Administrator did not have planned activities in place for residents in facility. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: Five (5) residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel service four (4) residents in the facility. Residents medication are centrally stored in a locked cabinet in the kitchen area. The first aid kit has missing items like thermometer, tweezers, manual, adhesive tape, etc. Additionally, the kit contained expired BENDARYL itch stopping cream and NEOSPORIN antibiotic pain relieving cream, both creams expired on 05/2021. LPA reviewed two (2) of the residents (R1 & R2) medications and observed that Pravastatin Sodium (10mg) and Citalopram HBR (10mg) were prescribed to be given in the AM, but Administrator & staff administer the medicaitons in the PM. Additionally, one of the medications for R2 was administered but the staff did not properly document the MAR and did not indicate that the medication has been administered. Disaster Preparedness: The facility has not conducted an emergency drill on a quarterly basis for all staff and residents. Administrator cannot provide LPA a copy of the Emergency and Disaster plan for review. Residents with Special Health Needs: Administrator has not made a report in writing to the local fire department that oxygen is in use at the facility and facility has bedridden residents. Administrator stated that staff have not received training regarding operation of the oxygen equipment. Pursuant to Title 22, deficiencies were cited on the attached 809D. Exit interview conducted, appeal rights provided, and copy of report were provided to the Licensee/Administrator, Irene Deanon.the state’s words, verbatim · CDSS document, Sep 16, 2023

Type of visit: Office

Licensing Program Analyst (LPA) Ashley Calderon and Licensing Program Manager (LPM) Fernando Fierros conducted a virtual office meeting on possible changes of property and met with Licensee Evangeline Ursua to discuss the purpose for todays visit. The following was discussed: Status of Facility: Facility has a census of 6 residents and 2 residents are on hospice. Lease: Ireane Deanon and Evangeline 'Lyn' Ursula both have 50/50 on the lease of property. Irene Deanon was not able to attend this meeting but will be informed on what was discussed in todays meeting by Lyn. Lease expires on either Sept 2022. Licensee will provide to the department a copy of the renewed lease by COB 8/22/22. Control of Property: LPM Fierros notified Lyn on possibility of forfeiting property if they lose Control of Property . Property of Ownership : Landlord of the property Anthony ' Tony ' Franco. Franco discussed with Ursua that he would like to raise the rent and possibly convert the detached garage to ADU to rent to an outside individual. Continue on 809c .... Miscellaneous / Options: Options were provided incase of changes: run unlicensed, find another property that application would be needed to submit to CAB , submit plan of operation, and CAB can expedite. In addition, changes to the property would require a fire inspection. If residents get moved to another facility a notice to the residents and responsible party is needed up to 60 days before relocation is needed. All residents would need to be relocated. Evaluation Manuel: Discuss and notified Ursua to review the following that can pertain do to Property Changes / Control of Property: -Control of Property and Expiration of Lease EM 3-0205 -Owner would like to convert garage into an ADU -Outside Clearances -EM 3-0133 - City permits for any changes to the facility -Change of Location process/procedures -Operating unlicensed EM 1-0050 -Fire Clearance EM 2-1115 -Immediate Civil Penalties -SB Leno Eviction Procedures , LPA Calderon will provide a copy. -AB949 Krekorian Resident Transfers, LPA Calderon will provide a copy. -Title 22 Eviction Procedure Section 87224 Deanon and Ursua are not in agreement in moving froward on changes of the property on their end and will talk to Landlord Franco. A meeting with Licensing to discuss updates will be held via MS Teams on 8/29/22. An exit interview was conducted with Licensee Evangeline 'Lyn' Ursula and a copy of this report was provided via email for signature.the state’s words, verbatim · CDSS document, Aug 19, 2022

Allegation investigated: Facility did not provide resident's file to resident's responsible party. Facility restricted resident's physical access to visits with family.

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Violeta Necesito Caregiver and explained the reason for the visit. LPA reviewed report with Irene Deanon administrator over the phone. The investigation consisted of the following: On 10/13/21 LPA Flores interviewed administrator, reviewed file for Resident #1(R1), and requested copies of Admissions Agreement, Hospital discharge and choice options form, Physician Orders for Life-Sustaining Treatment, Emergency Identification Information, Physician's Report, Needs and Care Plan, Power of Attorney, Hospice notes, Death report and Facility's Notes. On 5/23/22 LPA Flores contacted family member #3(F3). On 5/27/22 LPA Flores received via email visitation logs for February through May 2021. (CONTINUED LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Facility did not provide resident's file to resident's responsible party. It is alleged facility has not yet provided resident's file requested by responsible party. File review conducted for resident #1(R1) revealed R1 has a durable power of attorney notarized on March 16, 2017 which appoints family member #1(F1) and family member #2(F2) as the representative party. On 9/30/21 Responsible party requested a copy of R1's resident's file including care notes via email. Per administrator Irene Deanon an incident occurred in December 2020 and a new power of attorney was assigned which is why facility did not provide documents to family member #2. However, there is no additional or most current durable power of attorney for R1. Family member #3 clarify the incident but was not able to recall dates or if there was a most current power of attorney. Based on LPA's observation and file review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. Regarding allegation: Facility restricted resident's physical access to visits with family. It is alleged family members were barred from physically visiting R1 within the last 71 days of R1's life. Documents reviewed revealed R1 was receiving hospice services on 5/13/21 and passed away on 5/25/21. Facility Visitation Logs revealed facility had no in person visitors on February and March 2021 and were assisting with FaceTime and Window visits by appointment. Logs for April and May 2021 show visitors log-in, R1 had visitors from Hospice Agency and Physical Therapy, no other visitors were observed. Administrator stated that due to COVID 19 guidelines family members were not visiting indoors but were assisting with window and FaceTime visits which were not logged in the visitor's login sheet. R1's file revealed note dated 3/11/21 in which facility notes directives from family member #3 restricting visitations for R1. POA notes family member #2 as R1's responsible party. PIN 21.17ASC dated March 19, 2021, Notes General Visitation Requirements for Licensees for any visitor entering the facility regardless of their vaccination status. Based on LPA's observation and file review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. Health and Safety Code Title 22, Division 6, Chapter 3 are being cited on the attached LIC 9099D. Exit interview was conducted with Violeta Necesito Caregiver and a copy of the report, LIC 9099D, and Appeal Rights have been provided.the state’s words, verbatim · CDSS document, May 28, 2022 · control 28-AS-20211006153417

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(21) · Plan of correction due date: May 30, 2022

87468.2(a)(21) Additional Personal Rights of Residents in Privately Operating Facilities:(a) ... residents in... residential care facilities ... shall have all of the following personal rights: (21) To consent to have their relatives ...visit during reasonable hours, privately, and without prior notice. This requirement is not met as evidence by: Based on document review licensee did not ensure to allow visitor for R1, while R1 was on hospice which poses an immediate health, safety, or personal rights risk for persons in care.the state’s words, verbatim · CDSS document, May 28, 2022

Plan of correction: Administrator will certify in LIC9098 that will follow recommended guidelines regarding visitation by Community Care Licensing, or Department of Public Health and will submit certification by POC due date 5/30/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jun 3, 2022

87468.2(a)(19) Additional Personal Rights of Residents in Privately Operating Facilities:(a) ... residents in... residential care facilities ... shall have all of the following personal rights: (19) To ....purchase photocopies of their records. Photocopied records shall be provided within two (2) business days... This requirement is not met as evidence by: Based on document review licensee did not ensure POA responsible party for R1 received a copy of R1's file which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2022

Plan of correction: Administrator is to provide a copy of R1's file to responsible party listed on POA by 5/30/22 and submit a copy of acknowlegment of receipt by POC due date 6/3/22 to the department.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with Administrator Irene Deanon and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. The facility cares for elderly residents and is allowed to have 6 hospice residents. There is currently no resident on hospice. Facility is licensed to serve 6 residents over the age of 60, 6 non-ambulatory of which 6 may be bedridden and has a hospice waiver for 6. Facility is a one story building located in residential area. Facility serves dementia residents and has auditory devices in exit doors. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located at the entrance of facility. Sign in sheet, hand sanitizer, gloves and masks are available. Staff conducted a routine symptom screening of LPA at the time of entrance and have a sign-in policy as required per COVID-19 procedures. All staff were observed to be wearing mask during this visit. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction. Resident bedrooms were inspected. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. All bathrooms have the required grabs bars and non-skid mat. The hot water was between 105.4 - 106.2 degrees which is within the required 105 - 120 degrees. Cleaning supplies locked in the laundry area and under kitchen sink are inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the living room, dining room, small TV room and patio area. These areas are clean and have the required furniture. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Continue 809C LPA observed two fire extinguishers are fully charged. Smoke/carbon monoxide detectors were tested and in working condition. LPA reviewed residents and staff records. Residents' records were found to be complete and current. Staff files were reviewed, and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA reviewed residents' medications. Medications are documented properly and stored appropriately. Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview was conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 12, 2022

Allegation investigated: Facility staff did not observe changes in resident's condition.

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with caregiver Paulette Leyrit and explained the reason of the visit. Romina DSouza arrived a few minutes later. The investigation consisted of the following: On 8/3/21 LPA conducted interviews with administrator, staff #1(S1), #2(S2), and residents #1(R1), #2(R2),#3(R3),#4(R4). LPA reviewed residents files and requested copies of staff/resident roster, physician's report, needs and care plan, emergency identification information, appraisal, caregiver notes, and medication sheets for R1,R2,R3,R4, and resident #5(R5). On 8/4/21 LPA attempted to contact R5's responsible party. On 8/19/21 LPAs Flores and Mora requested copies of the following documents: Narrative charting, identification and emergency information, Home health care field notes, medication profile, consent to treatment, propose plan of services, transfer and discharge information for resident #5, facility's visitor log for 7/18/21 to 8/13/21, vital caregiver's notes from 7/19/21 to 7/26/21, staff roster and staff schedule. (CONTINUED ON LIC 9099C) Substantiated LPAs interviewed licensee and staff #4 and conducted interviews over the phone with hospice nurse and staff #3, attempted to conduct interview over the phone with staff #4 and resident #5's responsible party. On 10/7/21 LPA Flores requested Investigator Bureau (IB) to obtain medical records for R5. On 10/26/21 LPA Flores received documents from IB investigator Veronica Padilla. The investigation revealed the following: Regarding allegation: Facility staff did not observe changes in resident's condition. It is alleged R5 was taken to ER on 7/24/21 after responsible party found R5 "slumped over" at the dining table during an unannounced visit. Responsible party asked staff to check his blood pressure and blood pressure and heart rate were low. On 8/3/21 LPA Flores reviewed R5's physician report, resident appraisal, hospital discharge, appraisal/needs and care plan and facility's notes. Appraisal/needs and care plan notes on socialization: "low blood count: monitor for any ill effects of blood transfusion on 6/30/21 and 7/12/21: being weak/feeling tired." Hospital discharge dated 6/30/21 notes R5 was seen for a medical procedure. Facility's notes showed R5 was taken by responsible on 7/12/21 for a medical procedure. On 8/3/21 LPA attempted to interview 4 residents at the facility but was not able due to cognitive skills. On 8/19/21 LPA reviewed facility's daily assessment on 7/24/21 there are no notes for R5 at 7:00am or during 2nd shift. Per administrator R5 was under home health care services and was visited twice a week for services, administrator was informed that R5 woke up around 10:00am and was assisted with a shower due to bowel movement. Staff #3 stated to not know what occur or regarding noticing changes in condition. 4 out 4 staff were aware of R5's health condition and procedures to take in case a change is observed. Hospice Nurse stated to be at the facility for another resident and was taking notes in dinning room when R5 was sitting at table and responsible party arrived and requested 911 be contact, and was taken by ambulance around 2:00pm. On 10/26/21 LPA Flores reviewed medical records and Hospital Patient Information Sheet notes R5. Based on LPA's document review, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Romina DSouza lead caregiver and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 16, 2021 · control 28-AS-20210727121037

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Nov 17, 2021

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation... This requirement is not met as evidence by: Based on documents reviewed and interviews R5 was not observed for change in condition on 7/24/21 which poses an immediate health, safety, or personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2021

Plan of correction: Licensee will certify by LIC 9098 by 11/17/21 to ensure change in condition of all residents is observed, and will provide in service training to staff and submit documentation by 11//1921.

Allegation investigated: Facility did not provide resident's file to resident's responsible party.

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Irene Deanon and Assistant Administror Evangeline Ursua and explained the reason for the visit. The investigation consisted of: LPA conducted an interview with Administrator Irene Deanon and Assistant Administrator Evangeline Ursua at 11:00am -11:45am. LPA obtained copies of Staff and Resident Rosters, reviewed Resident 1's (R1) file and collected copies of the following documents from R1's file: Physician's Report for Residential Care Facilities for the Elderly (LIC602A) dated 03/04/20, Unusual Incident/ Injury Report (LIC624) dated 03/10/21, Identification and Emergency Information (LIC 601) and copy of R1's Durable Power of Attorney dated 3/16/17. LPA also conducted a telephonIe interview with R1's family member at approximately 10:00am. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Facility did not provide resident's file to resident's responsible party, it is alleged that facility staff did not provide R1's responsible party (RP) with a copy of R1's Needs and Services Plan and it is also alleged that facility staff have not responded to R1's RP request for copies of R1's file. Interview with both Administrator Irene Deanon and Assistant Administrator Evangeline Ursua revealed that they have not received a request from R1's RP for copies of any documents or a request for a copy of R1's resident file. Interview with R1's RP revealed that they had not made a formal written request for any copies of any documents pertaining to R1 or their facility file. R1's RP stated that they would follow proper protocol and make a formal written request to facility licensee/ administrator. Based on interviews conducted with Administrator Deanon, Assistant Administrator Ursua, R1's RP and LPA review of R1's file, there was not enough supportive evidence to concur with the reported allegation. Although the allegation 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 allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Administrator Irene Deanon.the state’s words, verbatim · CDSS document, Aug 16, 2021 · control 28-AS-20210806170224

Allegation investigated: Facility falsified documents

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit in response to the above allegation. LPA met with Assistant Administrator, Lyn Ursua who allowed entry into the facility and assisted with today's visit. In response to the allegation that the facility falsified documents, specifically that facility falsified responsible parties signature on the Appraisal Needs and Services Plan for Resident #1. The investigation consisted of interview with Resident #1 family member, Staff #1, and review of Resident #1's file. LPA Rea obtained a copy of Resident #1's Appraisal Needs and Services Plan dated 3/29/19 from resident #1's family member. Resident #1's family member stated that she did not sign the Appraisal dated 3/29/19. LPA Rea reviewed copy of Appraisal Needs and Services Plan dated 3/29/19 from Resident #1's file at the facility. LPA observed that the signature did not appear to match the signature on the copy provided by Resident #1's family member. Staff #1 stated that she does not believe that the facility falsified the documents. Review of other documents, observed in Resident #1's file, show that Resident #1's responsible party/family member signature was not consistent. Unsubstantiated Based on LPA's observations and interviews, investigation revealed: 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. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator, Lyn Ursua.the state’s words, verbatim · CDSS document, Jul 14, 2021 · control 28-AS-20210707084421