Annika Grace Care Home

Allegation investigated: Facility staff did not provide records to resident's authorized representative.

On 10/09/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above allegation. LPA arrived at the facility at 10:00 a.m. and was greeted by the administrator Jozam Batulan. LPA explained to Administrator the purpose of the visit. Entrance interview conducted. At 10:10 a.m. LPA and administrator Jozam conducted a physical plant tour to ensure the health and safety of the residents in care. No issues or concerns were observed. Allegation: Facility staff did not provide records to resident's authorized representative. It is alleged facility did not provide copies of Resident #1's (R1) facility records to R1's legal representative. To investigate the allegation LPA conducted an interview with the Reporting Party (RP) on 07/21/2023 and an interview with the facility administrator on 07/26/2023. Interview with administrator revealed person(s) listed on R1's Admission Agreement were designated representative(s) for R1. (Continued on LIC9099-C) Unsubstantiated On 07/26/2023 LPA reviewed and obtained copies of R1's records relevant to the investigation. LPA's review of R1's Admission Agreement, revealed R1 was admitted to the facility and the responsible person(s) listed on the document is different from representative mentioned in this complaint. Furthermore, LPA did not find a legally binding document on file that designates the representative mentioned in this complaint as conservator or POA. Based on record review and interviews, the allegation facility staff did not provide records to resident's authorized representative is Unsubstantiated at this time. No deficiencies issued. Exit interview conducted. Report signed and delivered.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 31-AS-20230718160426

Type of visit: Required - 1 Year

On 10/09/23 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator Jozam Batuian. LPA observed covid-19 signs at the front door and required postings were observed in the entry area. LPA Rios explained the purpose of the visit. At 10:10 a.m. LPA and administrator Jozam conducted a physical plant tour to ensure the health and safety of the residents in care. The following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen. Bedrooms: There were six (6) bedrooms of which four (4) are designated for residents' use. Three of the bedrooms are currently occupied. One (1) room is currently vacant. Rooms occupied by residents were properly furnished with appropriate beddings and linens with sufficient lighting. A hallway closet by the bedroom was observed to store extra linens. Bathrooms: There are three (3) bathrooms. Two (2) are designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 11:48 a.m. and read 110.6 degrees Fahrenheit. Common Areas: These included the living area 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. (Continued on LIC809-C) The smoke alarms are dual carbon monoxide detectors they are hired wired and interconnected. Administrator tested smoke/carbon detectors at 12:00 p.m. and were observed to be functioning properly. The fire extinguisher is located in the kitchen and the laundry room with purchase date 08/22/23. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a shed used for storage. The laundry room leads to the garage and is kept locked and inaccessible to residents in care. Detergents and cleaning products are kept in the laundry room locked. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms at 12:10 p.m. 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 at 12:47 p.m. Medications: Medication and Medication Records were reviewed for proper documentation. LPA review of Centrally Stored Medication and Destruction Records (CSMDR) for two (2) of two (2) residents revealed medication dosages were inaccurate for both residents. According to administrator medication dosage taken had been updated but he had not had a chance to update the dosage on CSDMR. LPA observed Destruction log record was missing for medication indicated discontinued on (CSMDR). Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency observed during the visit. Exit Interview Conducted. Appeal Rights provided. A copy of the report Issued.the state’s words, verbatim · CDSS document, Oct 9, 2023

Allegation investigated: Facility admitted or retained a resident with stage 3 pressure injury.

On 06/27/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit for the above allegation. LPA arrived at the facility at 11:47 a.m. and was greeted by the administrator Jozam Batulan. LPA explained to Administrator the purpose of the visit. Entrance interview conducted. At 12:00 p.m. LPA and administrator Jozam conducted a physical plant tour to ensure the health and safety of the residents in care. No issues or concerns were observed. From 12:15 p.m. to 2:40 p.m. LPA reviewed resident records and obtained documents relevant to this investigation. From 2:41 p.m. to 3:30 p.m. LPA interviewed credible witnesses. Allegation: Facility admitted or retained a resident with stage 3 pressure injury. It is alleged facility admitted a resident#1(R1) with a Stage 3 pressure injury and (R1) has been receiving wound care by a home health agency at the facility. (LIC9099-C Continued on to next page) Substantiated (LIC9099-C Continued) Interview with the administrator revealed R1 was admitted to the facility with a pressure injury and R1 was being provide wound care by two home heath agency prior to admittance to facility and currently. Records revealed home health agency has been providing assistance with wound care from April 2023 and currently. Two credible witnesses corroborate R1 was or is receiving wound care for a Stage 3 pressure injury. Based on record review and interviews, the allegation mentioned is Substantiated at this time. Deficiencies issued per CA Code of Regulations, Title 22 (refer to LIC9099-D). Report signed and delivered. Appeal Rights provided. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 27, 2023 · control 31-AS-20230619091039

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Jun 29, 2023

87615(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to ensure above regulation by retaining R1 with a stage 3 pressure injury, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2023

Plan of correction: Licensee will abide by state licensing regulations, and will not retain any resident with a prohibited health condition. Licensee will communicate with Home Health and R1's family about regulation cited and will certify the regulation has been understood and complied with. Licensee will submit to LPA arrangements made for R1 so that facility may be in compliance with regulation by the POC due date.

Type of visit: Case Management - Deficiencies

On 06/27/2023 in conjunction with an initial complaint visit control number 31-AS-20230619091039, Licensing Program Analyst (LPA) Evelin Rios completed an unannounced CASE MANAGEMENT- Deficiencies visit. LPA met with Administrator Jozam Latayan Batulan, explained the purpose of the visit. At 12:15 p.m. LPA reviewed two (2) out of two (2) resident records. Review revealed resident #1(R1) and resident#2 (R2) records are incomplete by missing the following: Identification and emergency information, pre- admission appraisal, needs and services and functional capabilities. Administrator confirmed they did not complete documentation missing in residents' records. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D). Copy of this report provided, appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 27, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jul 7, 2023

87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to ensure complete and required records were created and kept for two(2) out of two (2) residents in care which poses a possible health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2023

Plan of correction: Licensee will document ID/Emergency Information, Functional Capabilities, Reappraisals, and Incident Reports for R1 and R2. Submit copies to LPA by POC due date. If R1 is transfered out of the facility the Licensee will notify LPA of such by POC due date.

Type of visit: Required - 1 Year

On 9/29/22 Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator. LPA observed covid-19 signage, hand sanitizer, PPE supplies and a visitor sign in log. LPA was asked by the Administrator to sign in using the infection prevention sign in log. The purpose of the visit was explaoned and an entrance interview was conducted. LPA initiated a physical plant tour at 11:45 a.m., Facility is a Residential Care Facility for the Elderly which was licensed for six (6) non-ambulatory, of which one (1) may be bedridden. Facility has been approved for a hospice waiver for six (6). LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area and has a date of purchase of 9/29/2022. Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a temperature of 78 degrees Fahrenheit. LPA observed there to be sufficient stock of one-week non-perishable foods and two day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. There is a clean covered shaded area in the back yard and there are no bodies of water. No deficiencies issued during today’s visit. Report was signed and delivered by Administrator and an exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 29, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Angelica Arambulo conducted an announced visit to the facility. LPA met with applicant Jozam Batuan. His administrator certificate # 6057138740. The facility has a fire clearance for 5 Non ambulatory and one bedridden in room 1. pre checklist was reviewed with the applicant during the visit. Upon entry LPA temperature was checked and documented. PPE supplies were at the entry way and tour was given. The facility is a one story home with 5 bedrooms. 4 for resident use and one staff room. There are 2 1/5 bathrooms for residents use. The rooms had required lighting, furniture and linens. All bathrooms had grab bars, non-slip rugs and towels. The linen cabinet had additional towels, bed sheets, and blankets. The kitchen was checked and there is food supply for 7 days non-perishable and 2 days perishable. There is a cabinet stocked with bottled water and emergency food. Each cabinet through out the kitchen and bathrooms had the magnetic lock which automatically locks . Cleaning solutions are locked away and separate from food items. Knives are locked away under the kitchen sink. The medication cabinets have a lock and has the first aid kit that is complete. The stove had the plastic cover for the knobs as extra security for any dementia residents. Water temperature was measured at 115.9. The smoke detector was checked and is hard wired throughout the facility. The smoke detector is a combination with the carbon monoxide detector. There is a fire extinguisher that is full in the dining area. The front and back yard are well manicured and maintained. There is sign's in the home for COVID 19 PROCEDURES and is visible for visitors and residents. Ombudsman poster is up in the common area. The visitor sign outside the home will need to be updated for essential workers and outdoor visitations. The common areas were well lit and furnishings all appropriate for resident usage. Activity schedule is posted and will be updated to residents capabilities. There is a menu posted along with the emergency disaster plan. The facility floor plan giving emergency exits. Residents personal rights, Theft and loss policy, facility house policy, and resident council notifications. A register of residents shall be updated once the facility is in operation. LPA will be emailing the report to the applicant along with a checklist of documents he needs for staff files, facility files and resident files. Administrator / applicant had his file there with his first aid certificate and other required papers. The applicant will be in contact with LPA for assistance with his paperwork. email verified to be correct. home phone line will be connected next week and applicant will update LPA. The phone on file is his personal cell phone. A staff schedule will be updated and submitted along with the liability insurance once license is approved. Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Unit (CAU). You will be notified by the CAU Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAU Analyst. Failure to comply could affect approval of your license. Exit interview held.the state’s words, verbatim · CDSS document, Sep 2, 2021

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Method: Telephone call with CAB Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant/administrator was verified by correctly answering identity verification question. During COMP II, applicant/administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Jul 23, 2021