Jackie's Hideaway A

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Margarita Piza and explained the reason for the visit. At 11:50am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are battery operated. There is a carbon monoxide detector near the kitchen that functions properly. There are two fire extinguishers located near the kitchen and at the entrance of the facility. The charge date is 7/27/2022. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled prescribed and PRN medications were locked in the kitchen cabinets. Bedrooms: There are six (6) bedrooms designated for residents' use. All six rooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are five (5) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 109.4 and 120 degrees Fahrenheit. No cleaning supplies, toxins or chemicals were stored in resident bathrooms during inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Although not in use, the fireplace was properly screened with no key present to ignite. Also, no tools for the fireplace were in sight or accessible to residents in care Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. There is no swimming pool or bodies of water. The outdoor area was free of hazards. The laundry room is located by the kitchen. No cleaning supplies and detergent were observed or accessible to the residents. The laundry room is inaccessible to residents. Adjacent to the laundry room is staff office that is also inaccessible to residents. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: Medication and Medication Records were review for proper documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit Interview Conducted. A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Sep 20, 2022

Allegation investigated: Resident 1 (R1) sustained an unexplained fracture while in care Licensee/Staff failed to seek timely medical attention

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan to deliver the findings regarding the allegations, ‘Resident sustained an unexplained fracture while in care of staff and, Facility staff failed to seek timely medical attention for resident. On 03-20-2019, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s, Investigation Branch. The investigation was assigned to Investigator, Dennis Douglas. On 3/22/2019 an initial 10-day visit was conducted at Jackie’s Hideaway B Facility # 197609341 by LPA N. Gillyard to initiate the investigation. On that day LPA Gillyard conducted tour of the facility reviewed records and obtained copies of pertinent records. During the course of the investigation information obtained revealed that the complaint was written in error for Jackie’s Hideaway B, therefore on 1/30/2020 a new complaint was generated for this facility. Substantiated Medical records were requested by the office of Investigations. The records were received and reviewed on 04-22-2019 by Investigator Douglas. Additionally, on 4/10/2019 and 7/1/2019 Investigator Douglas conducted interviews with, administrator, staff and other relevant parties. The investigation revealed that on 03-17-2019 Resident #1(R1) was showing signs of pain in the hip and or leg. The resident was unable to express pain verbally. Facility staff members attempted to assess the resident to find out what was hurting by the resident’s reaction when the resident was moved. The staff logs indicate that R1 complained about pain on the left hip and leg on 03-18-2019. In-addition the resident had a temperature of 102 degrees and appeared to show signs of abdominal pain. At which time the family was notified. Staff interviews revealed resident had previous falls approximately 3 weeks prior, staff denied R1 sustained a recent fall and denied knowing the cause for the recently developed pain. On 03-19-2019 the Administrator had spoken to a Kaiser Nurse Practitioner who recommended that R1 be sent to the hospital, to which the facility Administrator initially declined. The Administrator acknowledged it was ultimately the resident’s family/POA (Power of Attorney) to have R1 transported to the Kaiser hospital as a precaution. Additionally, on 3/17/2022 LPA Avetisyan requested Pre hospital Care Report Summary from the Los Angeles Fire Department Emergency Medical Services. Records were received and reviewed on 3/30/2022. According to the paramedic documentation they responded to a call for a 71 year old with complaint of left hip pain from ground level mechanical fall. Reviewed medical records revealed upon hospitalization X-rays of R1’s left hip were taken. The x-rays indicated that R1 sustained mildly displaced/impacted fracture of the femoral neck. Staff interviews confirmed that R1 was complaining of pain for about 3 days and administrator declined to obtain medical care. Medical care was obtained at the request of R1’s POA. Therefore, the allegations of Resident 1 (R1) sustained an unexplained fracture while in care and Licensee/Staff failed to seek timely medical attention are substantiated. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, May 17, 2022 · control 31-AS-20200130140143

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464 · Plan of correction due date: May 19, 2022

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on information obtained during the course of the IB investigation the licensee did not comply with the section cited above, as R1 suffered a broken bone unknown to staff, which posed an immediate health, safety or personal rights risk to R1.the state’s words, verbatim · CDSS document, May 17, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training related to the cited section Verification of scheduled training with the trainers credentials will need to e submitted by 5/19/2022 and completed by 6/2/2022. Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87464

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1)(2) · Plan of correction due date: May 19, 2022

(1) The licensee shall arrange, or assist in arranging, for medical … care appropriate to the conditions and needs of residents. (2) The licensee shall provide assistance in meeting necessary medical … needs. This includes transportation which may be limited to the nearest available medical … facility which will meet the resident's need… This requirement was not met as evidenced by: Based on information obtained during the course of the IB investigation the licensee did not comply with the section cited by not obtaining medical care when staff observed R1 in pain and recommended by nurse practitioner which posed an immediate health, safety or personal rights risk to R1.the state’s words, verbatim · CDSS document, May 17, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training related to the cited section Verification of scheduled training with the trainers credentials will need to e submitted by 5/19/2022 and completed by 6/2/2022. Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87465

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. Upon arriving, LPA contacted the facility, and spoke to Co-Administrator Margarita Piza, who reported to LPA, there are not any active or past COVID cases at the facility. All (12) staff and (6) residents have been vaccinated. The current census is (6). LPA was greeted at the front door by the Co-Administrator Margarita, who allowed LPA to enter. LPA’s temperature was not taken, and LPA had to instruct Co-Administrator to take temperature. LPA signed in the visitor book, and observed hand sanitizer at the front door. COVID-19, CDC, Department of Public Health, and Licensing postings were observed on the walls throughout the facility. The Administrator Taly Tal, was contacted and notified of the visit and arrived at the conclusion of the inspection. The infection control inspection began with the Co-Administrator escorting LPA throughout the facility. The facility has (6) private bedroom, and (5) bathrooms. All bedrooms were properly furnished and with clean furnishings. Common areas were observed to be clean, including bathrooms; with soap and towels and hand washing signs posted. LPA conducted a mitigation plan review with the Co-Administrator, to obtain information on how the facility has implemented the plan. The Co-Administrator reported to LPA, the facility continues to surveillance testing, by rotating staff every (3) weeks for COVID testing. The facility keeps documentation of the test results and other pertinent information pertaining to COVID-19. Administration continues to conduct training to staff in relation to COVID-19. Staff have been notified that there is a paid sick leave policy in place. PPE, chemicals, cleaning supplies, emergency food and water, personal hygiene supplies, and paper products are stored in the locked unit, located in the backyard of the facility. Perishables are also stored with (3) refrigerators stocked with food for the facility. LPA observed the facility has Licensing requirement for food supply. Currently, the facility has sufficient staff. The Co-Administrator informed LPA that they continue to implement the best practices for their facility; which has kept them COVID-19 free from residents. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases. Exit interview was conducted with Co-Administrator, and Licensee and copy of report was provided.the state’s words, verbatim · CDSS document, Aug 19, 2021