Carmel Oaks Assisted Living

Allegation investigated: Staff did not safeguard residents’ personal belongings.

Licensing Program Analysts (LPAs) Sandra Urena and Emili Peraldi conducted a subsequent visit to investigate the allegations listed above. The LPAs met with Administrator Nirvana Ghaemi and explained the reason for the visit. On 01/11/2023, Licensing Program Analysts (LPA’s) Sandra Urena, and Ashley Smith conducted an initial 10-day unannounced visit to investigate the allegations listed above. The LPAs met with Administrator Nirvana Ghaemi and explained the reason for the visit. At 9:25 a.m., the LPAs conducted a brief tour of the physical plant. From 9:30 a.m. to 10:21 a.m. LPAs conducted resident interviews, and from 10:30 a.m. to 11:08 a.m. LPAs conducted staff interviews. Record review was done from 11:10 a.m. to 11:25 a.m. Continues on LIC9099C... Substantiated Staff did not safeguard residents’ personal belongings. On the allegation that ‘Staff did not safeguard resident personal belongings’; it is the complainant’s concern that the responsible parties for R1 purchased new clothes and they were missing. To investigate the allegation, the LPAs conducted interviews. The Administrator stated that they believe that R1’s items were stolen by a former staff. The administrator called R1’s family and said they could provide new clothes or pay for what was taken. Additionally, the administrator stated that they did not have an inventory of R1’s items because many of the residents didn’t have ‘much’. However, the administrator said they were going to start to log the new items and said they were going to do this with R1’s family. The interview with R1’s responsible parties revealed that they had communicated with the administrator about the missing clothing items, and that the administrator gave them two different reasons for the clothing missing. First the administrator stated, ‘R1 must have thrown their clothes away’, and when the responsible parties replied, ‘But staff are supposed keep an eye on residents’, then the administrator changed the reason to, ‘Probably the staff no longer working at the facility must have taken them’. The administrator asked about the total value of the clothing missing, and the responsible party stated that it was somewhere in the amount of $200 dollars. The responsible parties for R1 stated that they had received payment for the lost clothes. Based on the information obtained through interviews, there is sufficient evidence to support the allegation that staff did not safeguard residents’ personal belongings. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, and the Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D): Citations were issued. Exit interview conducted, today's report, and appeal rights were reviewed and issued. Pg.2 Staff did not prevent resident sustaining injury due to fall. On the allegation of ‘Staff did not prevent resident sustaining injury due to fall’, it is the complainant’s concern that R1 can’t walk or move that well. To investigate the allegation the LPA conducted interviews. The interview with the complainant on 01/06/2023 at 9:54 a.m., revealed that R1 can hardly walk and stand by themselves. R1 needs to be in a wheelchair and be assisted when they need to go to the bathroom or take a shower. Although the medical record review indicated that R1 is ambulatory, record review of a needs assessment plan dated between 03/21/2021 to 12/29/2022 indicates that R1 is at risk of falls; the assessment plan indicated that R1 should be monitored and encouraged to use a walker or wheelchair. Record review revealed that R1 has a condition that affects their mobility. Interview with the administrator revealed that R1 goes to the bathroom on their own, and that R1 is also at risk for falls, however the administrator did not elaborate as to the measures taken by staff to ensure that R1 is monitored and or assisted while going to the bathroom on their own to prevent falls. The LPA interviewed the staff who stated that some residents are at risk of falls, however staff stated that they monitor the residents while they are awake, and sometimes the residents get up in the early hours of the morning or night and they may sustain falls while trying to get up from the bed or go to the bathroom on their own. To investigate the allegation the LPA interviewed residents, staff, and administrator. Two out of three residents were able to answer questions related to the falls. Two stated that they had not sustained falls. Based on the information obtained through interviews, and record review, although there is sufficient evidence to support the allegation that two residents out of five residents sustained falls while in care, the falls occurred while the resident attempted to independently go to the bathroom either at night or early morning. Therefore, the allegation is deemed Unsubstantiated at this time. Staff left resident in soiled diaper for extended period of time. On the allegation that ‘Staff left resident in soiled diaper for extended period of time’; it is the complainant’s concern that residents smelled like they were wearing soiled diapers. To investigate the allegation, the LPAs conducted interviews. The administrator claimed that R1 goes to the bathroom on their own, but that R1 also wears a diaper, however, R1 doesn’t use it, and primarily goes to the restroom and uses the toilet. The administrator further stated that the residents all have access to the diapers, but staff will also provide the resident with a new diaper as needed. Continues on page 3. Pg. 3 The interview with the complainant revealed that they don’t know how often the staff changes the residents’ diapers and could not say how many other times the residents smelled like they were wearing soiled diapers. Staff interviews revealed that R1 did not need assistance but said that they needed to monitor them, so staff will check in with R1 to make sure they are using the restroom. Record review did not indicate that R1 has incontinence needs. Based on the information obtained through interviews, although the allegation may have happened or is valid, there is not sufficient evidence to prove that the staff left the resident in soiled diapers for an extended period of time. Therefore, the allegation is Unsubstantiated at this time. Staff are not providing resident with adequate food service. On the allegation that ‘Staff are not providing resident with adequate food service’; it is the complainant’s concern that responsible parties for R1 purchase snacks for R1, however, when R1 runs out of snacks, the staff give R1 snacks that are for diabetics, and R1 is not diabetic. To investigate the allegation, the LPAs interviewed the administrator, staff, residents, and responsible parties. The staff stated that none of the residents are on special diets, but a couple of residents are diabetic, and staff cook meals that are low in salt. The administrator stated That R1’s responsible parties do bring R1 protein shakes, however the physician’s report does not state that R1 requires a special diet. R1’s responsible parties stated that they provide the facility with protein shakes for R1, because R1 needs to gain weight. However, R1’s responsible parties stated that R1 was being given by staff drinks designed for diabetics. Record review does not indicate that R1 is on a special diet. Based on the information obtained through interviews, and record review, there is not sufficient evidence to prove that the staff are not providing resident with adequate food service. Therefore, the allegation is Unsubstantiated at this time. Staff did not ensure resident was given showers. On the allegation that ‘Staff did not ensure resident was given showers’, it is the complainant’s concern that when R1’s visited the facility, they noticed that R1 was dirty, and had not had a bath. To investigate the allegation, the LPAs conducted interviews. Continues on Pg.4 Pg. 4 The interview with the staff revealed that R1 needs assistance to shower, and that staff provide assistance to R1 twice a week. The administrator’s interview revealed that any staff can assist R1 with showers. The interview with R1’s responsible parties revealed that on a recent visit R1 had different bad smells, and definitely could tell that R1 had not been given a shower recently. When asked by the LPA if they had asked staff how often they assisted R1 with showers, the responsible parties stated, ‘No’. Based on the information obtained through interviews, although the allegation may have happened or is valid, there is not sufficient evidence to prove that staff did not ensure resident was given showers. Therefore, the allegation is Unsubstantiated at this time. Staff did not provide privacy for residents. On the allegation that ‘Staff did not provide privacy for resident’, it is the complainant’s concern that while the responsible parties for R1 were trying to communicate with R1 via phone, the staff took the phone away from R1. To investigate the allegation, the LPAs interviewed the administrator and the responsible parties for R1. The administrator said that if residents want to use the phone, they can and there are no restrictions; the staff can also call if a resident requests assistance, but said they also leave the resident alone when they are on the phone. Administrator denied claims that they had ever received complaints about phone calls being interrupted. The interview with R1’s responsible parties revealed that on two different occasions when they were speaking with R1 on the phone, R1 was trying to explain, and tell me something, when a staff (don’t know who) abruptly took the phone away from R1, consequently R1 could not finish telling the responsible parties what they wanted to say. Based on the information obtained through interviews, although the allegation may have happened or is valid, there is not sufficient evidence to prove that staff did not provide privacy for resident. Therefore, the allegation is Unsubstantiated at this time. Exit interview conducted. Today’s report was reviewed and issued.the state’s words, verbatim · CDSS document, Jul 13, 2023 · control 29-AS-20230103142731

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jul 13, 2023

8721(b)Safeguard for Personal Property & ValuablesEvery facility shall take appropriate measures to safeguard residents' ... personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles...This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the licensee failed to safeguard and provide receipts for all personal property…, which resulted in R1’s clothing being lost, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 13, 2023

Plan of correction: POA: Administrator reimbursed the RP for the missing clothing. The POA has been cleared.

Allegation investigated: Staff did not give all of residents medication to authorized representative when resident left the facility.

Licensing Program Analysts (LPAs) Sandra Urena and Emili Peraldi conducted a subsequent visit to investigate the allegations listed above. The LPAs met with Administrator Nirvana Ghaemi and explained the reason for the visit. On the allegation that ‘Staff did not give all of resident’s medication to authorized representative when resident left the facility’; it is the complainant’s concern that the facility staff withheld one of the Resident’s #1(R1) medication, and as of 06/13/2023, some medications are still being order from the pharmacy and being delivered to the facility, even though the R1 left the facility some months ago. To investigate the allegation the LPAs interviewed the administrator on 06/21/2023 at 2:21 p.m., the administrator stated that all medications were given to R1’s responsible party when the resident left the facility. The administrator provided the LPAs with a letter signed by the R1’s responsible party dated 01/12/2023. The letter stated that ‘Everything is checked and there are no concerns. All belongings are with the resident’s POA’. Continues on LIC 9099C... Unsubstantiated The LPA verified the authenticity of the letter with the responsible party, who stated that the letter was authentic. Additionally, the administrator stated that they had communicated with the pharmacy on 01/14/2023, and communicated with the doctor prescribing the medication to inform them that the resident not living at the facility anymore as of 01/12/2023. The administrator stated that the pharmacy did indeed refill four medications on 3/11/2023. The medications were delivered by the pharmacy and left with the facility staff in the evening hours. The administrator reviewed the medications the next morning, and discovered that the pharmacy had delivered medications for R1. The administrator stated that they communicated with the pharmacy about the medication delivered and was instructed to destroy the medications, which they did by placing all medications in water to dissolve it, then placing the medication in a can prior to disposing of it in the trashcan. The administrator provided the LPAs with the Centrally Stored Medication and Destruction Record (LIC 622) which recorded the medications delivered for R1. Based on the information obtained through interviews and record review, there is not sufficient evidence to support the allegation that Staff did not give all of resident’s medication to the authorized representative when resident left the facility. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 13, 2023 · control 29-AS-20230620141817

Allegation investigated: Resident developed pressure injuries while in care; Residents are sustaining falls while in care; Staff are causing the residents to choke on food; Staff are not addressing the residents’ hygiene needs while in care; Staff do not have planned activities for the residents; Residents are being locked in the home; Staff are serving expired food; Staff are pushing the residents while in care; Residents are left soiled; Staff are not providing adequate care and supervision to the residents.

Licensing Program Analysts (LPAs) Sandra Urena and Emily Peraldi conducted a subsequent investigation visit for the allegations listed above. The LPAs met with Administrator Nirvana Ghaemi and explained the reason for the visit. On 12/06/2022, Licensing program Analyst (LPA) Sandra Urena, arrived at 10:17 a.m., unannounced for an initial complaint inspection for the allegations listed above. The LPA met with Administrator Nirvana Ghaemi and explained the reason for the visit. At 11:50 a.m., LPA Urena and the Administrator conducted a physical plant tour. From 10:23 a.m. to 12:15 p.m., interviewed residents’, and residents’ responsible parties, and staff. At 11:10 a.m. obtained, and reviewed documents pertinent to the investigation. Continues on Pg 2. LIC9099 C... Unsubstantiated Pg.2 Resident developed pressure injuries while in care. On the allegation that ‘Resident developed pressure injuries while in care’; it is the complainants concern that a resident developed pressure injuries while in care. To investigate the allegation the LPA interviewed the resident’s responsible party (RP). The RP stated that the resident did not develop the injury while in care, and furthermore the resident was receiving care by a hospice agency. The LPA requested medical documents and conducted record review. The record review indicated that the resident was receiving care by a hospice agency. Based on the information received through interviews and record review, there is not sufficient evidence to support the allegation that the resident developed pressure injuries while in care. Therefore, the allegation is deemed Unsubstantiated at this time. Residents are sustaining falls while in care. On the allegation that ‘Residents are sustaining falls while in care’; it is the complainants concern that residents are sustaining falls. To investigate the allegation the LPA interviewed residents, staff, and administrator. Three out of three residents stated that they had not sustained falls. The LPA interviewed the staff #1 (S1)who stated that some residents are at risk of falls, however S1 stated that they monitor the residents while they are awake, and sometimes the residents get up in the early hours of the morning or night and they may sustain falls while trying to get up from the bed or go to the bathroom on their own. The resident's room has a night signal to ask for help when needed. The interview with the administrator revealed that two residents have sustained a fall within the last two months; the administrator emailed the Incident Report to the licensing department and informed the residents’ responsible parties of the falls sustained by the residents. Based on the information obtained through interviews, and record review, although there is sufficient evidence to support the allegation that two residents out of five residents sustained falls while in care, the falls occurred while the resident attempted to independently go to the bathroom either at night or early morning. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on Pg.3 LIC 9099C... Pg.3 Staff are causing the residents to choke on food. On the allegation that ‘Staff are causing the residents to choke on food’; it is the complainants concern that residents are given food items that are difficult for residents to eat. To investigate the allegation, the LPA interviewed the administrator, who stated that one resident almost choked on a piece of a grape, and that 9-1-1 was called. The resident was able to spit out the grape and was ‘ok’ afterwards. Still 9-1-1 was called to have the resident checked out. Residents’ interviews revealed that they are ok with the meals being served to them. Based on the information obtained through interviews, although there is sufficient evidence to support the allegation that one resident almost choked on food, there is not sufficient evidence to support the allegation that staff are causing residents to choke on food. There were no other incidents recorded where a resident chocked on food. Therefore, this allegation is deemed Unsubstantiated at this time. Staff are not addressing the residents’ hygiene needs while in care. On the allegation that Staff are not addressing the residents’ hygiene needs while in care’; it is the complainants concern that residents are only getting two showers a week, and residents are not assisted in brushing their teeth. To investigate the allegation the LPA interviewed the residents, staff and administrator. The staff stated that home health provides assistance with showers, and hygiene needs to three residents, the other two residents receive assistance from facility staff. The administrator stated that some residents receive assistance with showers from home health staff, and some receive assistance from staff at the facility. The residents get two showers a week, and more if needed. The residents brush their own teeth for the most part. The residents’ interviews revealed that they get assistance from a person that comes to the facility to help them with their showers. One resident stated that they don’t need help with hygiene needs. Based on the information obtained through interviews, there is not sufficient evidence to support the allegation that staff re not addressing the resident’s hygiene needs while in care. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on Pg 4. LIC 9099 C... Pg.4 Staff do not have planned activities for the residents. On the allegation that ‘Staff do not have planned activities for the residents’; it is the complainant's concern that residents don’t get activities. To investigate the allegation the LPA interviewed residents, staff, and administrator. The residents, interviews revealed that they participate in birthday celebrations, holiday get-together meals, and get to do activities such as coloring books. The residents have an outdoor area to get fresh air. The LPA observed an activity where the staff seems to be having a dance activity with the residents. Based on the information obtained through interviews and observation, there is not sufficient evidence to support the allegation that staff do not have planned activities for the residents. Therefore, the allegation is deemed Unsubstantiated at this time. Residents are being locked in the home. On the allegation that ‘Residents are being locked in the home’; it is the complainants concern that residents are being locked in their rooms. To investigate the allegation, the LPA interviewed two residents, staff and administrator. The two residents interviewed stated that they are not locked in their room. During the unannounced visits conducted by the LPAs, it has been observed that residents are sitting either in the living room, in their bedrooms, and occasionally outdoors. Administrator denied having residents locked up. Staff denied locking residents in their rooms. During the physical plant tour the LPAs noticed that the bedroom doors have knobs that cannot be locked from the outside of the room. The front and back doors to the facility were observed to have a signal system to alert if the doors are open. The LPAs observed residents exiting the to the backyard independently while the back door was unlocked, and the signal alarm was activated. Based on information obtained through interviews and observation, there is not sufficient evidence to support the allegation that Residents are being locked in the home. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are serving expired food. On the allegation of ‘Staff are serving expired food’; it is the complainants concern that staff are serving expired food to residents. On 01/11/2023, Licensing program Analysts (LPAs) Sandra Urena, and Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at 09:20 a.m. due to deficiencies observed during the investigation of Complaint Control # 29-AS-20230103142731. While conducting an assessment of the foods in the pantry, the LPAs observed that a box of approximately 15 containers of Ensure Plus supplements had expired, with an expiration date of 11/ 01/2022 and 12/01/2022. The allegation was Substantiated, and corrected on the same day 01/11/2023, as Administrator agreed to throw away the expired food. Continues on Pg.5 LIC 9099C... Pg. 5 Staff are pushing the residents while in care. On the allegation that ‘Staff are pushing the residents while in care’; it is the complainants concern that residents are being pushed by staff. To investigate the allegation the LPA interviewed residents, staff and administrator. The residents’ interviews revealed that they have not had any staff pushed them. The Administrators stated that they have not received any complaints by residents or residents’ responsible parties about being pushed by staff. Staff denied pushing residents. Based on the information obtained through interviews and observation, there is not sufficient evidence to support the allegation that Staff are pushing residents. Therefore, the allegation is deemed Unsubstantiated at this time. Residents are left soiled. On the allegation that ‘Residents are left soiled’; it is the complainants concern that residents are not being assisted with incontinence needs during the night. To investigate the allegation, the LPA interviewed residents about their incontinence needs being addressed by staff during the night. The interviews revealed that four out of six residents do not have incontinence needs, they are ambulatory, and two residents are being assisted with incontinence needs as needed. The LPA interviewed the administrator and the staff. The administrator stated that the staff check on the residents at night every two hours to see if they need assistance with incontinence needs. The staff stated that they check the residents every two hours, and change diapers as needed, but typically residents don’t need to be changed. Based on the information obtained through interviews, there is not sufficient evidence to support the allegation that residents are left soiled. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on Pg.6 LIC9099 C... Pg. 6 Staff are not providing adequate care and supervision to the residents. On the allegation that ‘Staff are not providing adequate care and supervision to the residents’; it is the complainants concern that the night shift is done by one staff member and is not enough to supervise all residents, and residents getting injured due to falls. To investigate the allegation the LPA interviewed residents, staff and administrator. The staff interviews revealed that residents sleep through the night and for the most part and do not need assistance assistance at night. Three out of three residents interviewed stated that they have not sustained falls and do not need assistance at night. The administrator stated that sometimes residents who are ambulatory, do get up to use the bathroom at night. Based on the information obtained through interviews , there is not sufficient evidence to support the allegation that Staff are not providing adequate care and supervision to the residents. Therefore, the allegation is deemed to be Unsubstantiated at this time. Exit interview conducted. Today’s report was reviewed and issued.the state’s words, verbatim · CDSS document, Jul 13, 2023 · control 29-AS-20221205152932

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Sandra Urena and Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:04 a.m. The LPAs met with Administrator Nirvana Ghaemi, and explained the reason for the visit. The LPAs, and the Administrator toured the physical plant areas at 10:20 a.m. inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable food and non-perishable food. At 11:50 a.m., the LPAs and the Administrator observed the kitchen knives to be stored in a locked cabinet drawer to the left side of the stove BEDROOMS: The resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three bedrooms for resident use; room#3 is vacant, room #4 and room #5 are currently occupied as staff rooms. RESTROOMS: Residents’ restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Proper hand washing signs were displayed, and paper towels were available. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. Continues on LIC 809C... The facility maintained a temperature of 73 degrees. All exits have functioning auditory devices. The LPAs and the administrator observed the required postings in the common area. The backyard has a covered outdoor area equipped with furniture for resident use. The side gate door is self-latching. There were no bodies of water noted. The garage is detached from the home. RECORDS: Residents’ records review began at 11:36 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:25 p.m. Medications are centrally stored and locked in a cabinet in staff’s room #4. Medications were labeled and checked for expiration dates. Medications are properly documented on the Centrally Stored Medication & Destruction Record (LIC 622), however the LIC622 for each resident, was not updated to reflect the current start of the medication. Three residents’ medications were audited for reliability of assistance with medications. The audit revealed that six out of six prescription medication bottles contained more pills than the actual number stated in the prescription bottle. Per the Administrator, they believe that the staff is transferring pills from a current prescription bottle to a newly received prescription bottle, consequently, the number of pills in the bottles audited did not reflect the amount of pills per the new filled prescription. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs discussed the new PIN changes regarding infection control. The LPAs obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, Staff schedule. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 30, 2023

Type of visit: Case Management - Deficiencies

On 01/11/2023, Licensing program Analysts (LPAs) Sandra Urena, and Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at 09:20 a.m. due to deficiencies observed during the investigation of Complaint Control # 29-AS-20230103142731. The LPAs met with Administrator Nirvana Ghaemi, and explained the reason for the visit. At 9:25 a.m. the LPAs conducted a brief tour of the physical plant. From 9:30 a.m. to 10:21 a.m. LPAs conducted resident interviews, and from 10:30 a.m. to 11:08 a.m. LPA’s conducted staff interviews. Record review was done from 11:10 a.m. to 11:25 a.m. During the course of the tour of the facility, the LPAs observed keys accessible (hanging from the hinge of the door frame) of the staff’s bedroom #4. Residents’ medication are located inside an unlocked cabinet inside bedroom #4, making the medication potentially accessible to residents in care. Additionally, LPAs observed medication in an unlocked cabinet in the unlocked bedroom #9. The LPAs interviewed the administrator about the medication observed in bedroom #9, and the administrator stated that the medication belonged to a resident that was no longer residing at the facility, and medication was not destroyed. While conducting an assessment of the foods in the pantry, the LPAs observed that a box of approximately 15 containers of Ensure Plus supplements had expired, with an expiration date of 11/ 01/2022 and 12/01/2022. Record review revealed that the Physician’s Report for Resident #1 was incompletely filled out. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Citations were issued. Exit interview conducted, today's report, and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Jan 11, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Jan 11, 2023

87555 (b)(8)-The following food service requirements shall apply: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Based on observation of foods found in the pantry, the nutritional drinks had an expiration of 11/ 01/2022 and 12/01/2022, which poses an immediate health and safety danger to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2023

Plan of correction: POC-Corrected today as Administrator agreed to throw away the expired food.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Jan 11, 2023

87465(h)(2) The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, medications were found in unlocked cabinets and bedrooms and accessible to residents in care, which poses an immediate health and safety danger to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2023

Plan of correction: POC: Administrator agreed to secure all medications.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Jan 11, 2023

87565(i) Prescription medications which are not taken with the resident upon termination of services…shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This requirement is not met as evidenced by: Based on observation, medications for a terminated resident were found in the facility, which poses a potential health and safety danger to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2023

Plan of correction: POC: Administrator agreed to destroy the medications....

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(b)(1) · Plan of correction due date: Jan 11, 2023

87458 (b)(1)-...A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases... This requirement is not met as evidenced by: Based on record review, the physician report on file for R1 was not completely filled out, which poses a potential health and safety danger to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2023

Plan of correction: POC: The adminitartor has agreed to have a current physicians report completly filled out in residents file by 1/25/2023. Administrator will fax physician's report to LPA by 1/25/2023.

Allegation investigated: Facility operating out of ratio.

On 10/14/2022, Licensing Program Analyst (LPA), Sandra Urena conducted an unannounced visit to investigate the allegation listed above. The LPA arrived at the facility at 11:45 a.m., and was greeted by the staff. The staff contacted the Administrator Nirvana Ghaemi via telephone and made them aware of the visit. The LPA waited for the Administrator to arrive, and explained the reason for the visit. At 12:12 p.m., the LPA, and the staff conducted a brief physical plant tour of the facility. At 12:45 p.m. The LPA requested residents, and staff records, and medication logs. The LPA reviewed the records from 12:50 p.m. to 1:55 p.m. Continues on LIC9099C... Substantiated On the allegation that the ‘Facility is operating out of ratio’, the Reporting Party’s (RP) concern is that the facility is serving more residents than it is licensed to serve. The facility is licensed to serve six (6) residents. The facility’s record review revealed that eight (8) residents were admitted, and living at the facility from 10/18/2022 to 12/06/2022. One resident left on 12/06/2022, and another resident left the facility on 12/09/2022. The LPA interviewed residents' responsible parties, and the interviews revealed that the eight (8) residents were living at the facility between the months of October 2022 and December 2022. The LPA interviewed the administrator, and the interview revealed that eight (8) residents were admitted to the facility, and were residing during a specific time of period between 10/2022 and 12/2022. On 12/06/2022, during a Case Management Deficiencies visit, the facility was cited Pursuant to Title 22 of the CA Code of Regulations: 87204-(a) A licensee shall not operate a facility beyond the condition and limitations specified on the license, including specifications of the maximum number of persons served who may receive services at any one time. Therefore, based on the records review, and interviews, the allegation that the ‘Facility is operating out of ratio’ is deemed to be Substantiated at this time. No additional citations were issued at this time. Exit interview was conducted with the Administrator. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 14, 2022 · control 29-AS-20221207153019

Type of visit: Case Management - Deficiencies

On 12/06/2022, Licensing program Analyst (LPA) Sandra Urena, conducted an unannounced Case Management-Deficiencies inspection visit at 3:10 p.m. due to deficiencies observed during the investigation of complaint control # 29-AS-20221205152932. The LPA met with Administrator Nirvana Ghaemi, and explained the reason for the visit. At 10:17 a.m., LPA Urena, and the Administrator conducted a tour of the facility. During the tour, it was observed that two (2) residents occupied bedroom#1, two (2) residents occupied bedroom #2, two (2) residents occupied bedroom #6, and one (1) resident occupied bedroom #5. Total number of residents was observed to be seven(7). The facility is licensed for a capacity of six(6) residents. The Administrator stated that the resident in bedroom #5 was fingerprinted, and was associated to the facility as an employee. The resident in bedroom #5 is not related to the Administrator or the licensee. The resident was not observed acting as an employee of the facility. Record review revealed that the resident in bedroom #5 was admitted as a resident to the facility on 9/16/2022, based on the Admission Agreement found on file, and the resident's POA is paying a board and care fee to the licensee. The resident passed away during the case management visit, consequently the licensee will not be required to inform the Fire Department of the over capacity. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Citations were issued. Exit interview conducted, today's report, and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Dec 6, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204 · Plan of correction due date: Dec 9, 2022

(a) A licensee shall not operate a facility beyond the condition and limitations specified on the license, incuding specifications of the maximum number of persons served who may recieve services at any one time. This requirement is not met as evidenced by: Based on observation and record review, the facility was serving seven residents, which is over the allowed capacity. This poses an immediate health and safety danger to persons in care.the state’s words, verbatim · CDSS document, Dec 6, 2022

Plan of correction: ADministrator agrees to send in writing to the department that they are aware that they may not accept more than six residents at any given time in the facility.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 11:35 a.m. This annual inspection had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Nirvana Ghaemi, and explained the reason for the visit. The LPA, with the guidance of the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable food; however, the facility does not have a sufficient seven-day supply of non-perishable food. At 11:50 a.m., the LPA and the administrator observed the kitchen knives to be stored in an unlocked cabinet drawer to the left side of the stove BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six bedrooms for resident use; however, Room #4 and Room #6 are currently occupied as staff rooms. At 12:15 p.m., the LPA and the administrator observed in Room #6 one bottle of medication located in the left hand side of the closet. The bedroom #6 was unlocked and the closet dore was open. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the visit, the LPA did not observe signage in bathroom #2 pertaining to proper hand hygiene. Proper signage and paper towels were promptly displayed. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a temperature of 73 degrees. All exits have functioning auditory devices; however, at the time of the visit, they front and rear door leading to the back yard were turned off. The LPA observed the required postings in the common area. The backyard has a covered outdoor area equipped with furniture for resident use. The side gate door is self-latching. There were no bodies of water noted. The garage is detached from the home. RECORD REVIEW: During today's visit, at arrival at 11:35 a.m., S1 was observed to be working at this facility. During todays’ visit at 12:30 p.m., it was observed that Staff #1 (S1) was not associated to the facility, and a file for S1 was not available. Per the interview with S1, S1 stated that they had been working at the facility for one week. A civil penalty was issued on 04/29/2022, noting that S1 could not return to the facility until the background check and association to the facility was complete. The LPA reviewed the Caregiver Background Check System during today’s visit and observed that S1 was not associated to this facility. Per the staff schedule, S1 worked on 12/17/2021, 12/18/2021, and today, 12/21/2021. INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 29, 2022

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.