Tiffany's Board & Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection. LPA met with the administrator, Flordeliza Sasada, and explained the purpose of the visit. The facility is licensed for six (6) residents, ages 60 and over, of which six (6) may be non-ambulatory and one (1) bedridden approved for bedroom #3. There is a hospice waiver approved for (1) resident. LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tools. The facility has 4 bedrooms (3 shared resident bedrooms, 1 staff room), 2 bathrooms, living room, dining room, kitchen, and detached garage. The backyard has a covered area with tables and chairs. The swimming pool is surrounded by a fence. There are no items obstructing the walkways. Smoke and carbon monoxide combo detectors are connected to the fire department. Facility has fire sprinklers. LPA observed sufficient food supplies of perishable and nonperishable. Knives and cleaning solutions are locked and inaccessible to the residents. The hot water temperature is measured within the required range of 105-120 degrees F. LPA reviewed (3) personnel files. Administrator's certificate expires on 1/31/28. Staff are receiving training and has current CPR certificates. LPA reviewed five (5) resident files, and the files contain the physician's report and TB test results or chest xray, consent forms, admission agreement, and resident rights. The medication are centrally stored and administering to residents as prescribed. The current Emergency Disaster Plan is in place. LPA issued technical violations for disaster drills, staff training, and resident reappraisals. No deficiencies issued today. An exit interview was held and a copy of this report, along with appeal rights, was given to the administrator.the state’s words, verbatim · CDSS document, Feb 19, 2026

The state marks this report as 6 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Flordeliza Sasada. The following12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. Facility has mitigation plan but will need to update into an infection control plan. Notice provided. Physical Plant/Environment Safety: The facility is located in a residential area which contains: Living room, kitchen, dining area, 4 Resident bedrooms, 2 bathrooms, laundry area and a detached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Cleaning supplies and toxic substances are inaccessible. Water temperature readings measured within title 22 regulations. Operational Requirements: A current Plan of Operation observed. FACILITY IS CLEARED FOR 6 AMBULATORY OR NON-AMBULATORY RESIDENTS. BEDRIDDEN FIRE CLEARANCE APPROVED FOR BEDROOM #3. HOSPICE WAIVER GRANTED FOR 1 Continued on LIC 809-C Personnel Records - Staff Training: Administrator on file is current Staff have criminal background clearances. Four (4) staff files were reviewed. Staffing: Sufficient staff observed during visit Resident Records - Incident Reports: A total of four (4) resident files were reviewed. Required documents observed on file Resident Rights - Information Required postings observed Food Service: Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for clients to use and to store their meals No cleaning supplies stored near food Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Incident Medical and Dental: First Aid Kid observed (4) of (4) Resident medications reviewed Disaster Preparedness: Emergency and Disaster Plan observed Residents with Special Health Needs: Currently (1) resident receiving home health services. Home health documents observed Inspection Tool was completed and no Title 22 deficiencies are being cited on todays visit. Exit interview conducted and a copy of this report was providedthe state’s words, verbatim · CDSS document, Apr 1, 2025

Allegation investigated: Resident sustained a stage 4 pressure injury while in care. Resident was diagnosed with sepsis and E-Coli. Staff did not seek medical attention to resident in a timely manner.

***This report serves as an amendment and supersedes the complaint investigation report dated 03/07/24. The purpose of the visit is to correct the deficiency page. The findings remain as Substantiated. *** On today visit, Licensing Program Analyst (LPA) Tao conducted a subsequent complaint visit met with staff#4, caregiver. The purpose of the visit was to correct the complaint deficiency cited on 03/07/24 for the Stage 4 pressure injury and to add the additional citation for neglect. On 09/12/22, Licensing Program Analyst (LPA) Tao conducted the initial complaint investigation for the allegations listed above. LPA Tao conducted a health and safety check and toured the facility with Licensee, Flordeliza Sasada. LPA observed the facility was clean and in good repair, had a minimum of one-week nonperishable foods and a minimum of two days of perishable foods, and had operable wash basins, showers/bathtubs, and toilets and LPA did not observe any immediate health and safety concerns. (-continued in LIC 9099C-) Substantiated ***This report serves as an amendment and supersedes the complaint investigation report dated 03/07/24. The purpose of the visit is to correct the deficiency page. The findings remain as Substantiated. *** On 11/18/22, a subsequent tele-visit was conducted by Investigator Brian Slatic, during the visit, Investigator Slatic interviewed staff from staff#1 (S1) to staff #4 (S4) which included Administrator/Licensee; interviewed resident’s representative (RR) from RP1 to RP3; interviewed local law enforcement (P1); obtained resident records from hospital and obtained records from local law enforcement. IB reviewed resident#1 (R1)’s facility file and any related documentation. On 03/07/24, LPA Tao conducted a subsequent visit to deliver findings. On 03/22/24, LPA Tao conducted another visit for the purpose to correct the complaint deficiency cited on 03/07/24 for the Stage 4 pressure injury and to add the additional citation for neglect. Regarding allegation: resident sustained a stage 4 pressure injury while in care. It was alleged that due to staff neglect, a resident had a stage 4 pressure injury on resident’s Sacro Coccyx area while in care. During the investigation, the department interviewed staff from S1 to S4, responsible party (RP) from RP1 to RP3, and Whittier Police Department. The department reviewed R1’s facility file and reviewed R1’s hospital records. Per interviews with staff, on 07/31/22, staff #1 observed R1’s buttock area was a little raw. On 08/02/22, staff #1 observed R1s sore opened up and R1’s responsible party was notified. On 08/04/22, staff #1 indicated R1’s coccyx area had skin peeling off and outer area was reddened and staff notified R1’s responsible party. On 08/05/22, staff reported R1’s pressure sore was equivalent to the size of a quarter coin. On the same day, R1 developed a severe fever of 100-degree Fahrenheit and staff notified R1’s responsible party. R1 was sent to hospital for observation and treatment. Upon admission to the hospital, R1 was diagnosed with a Stage 4 pressure ulcer. R1’s sore was as extremely large and required surgery. On 08/07/22, R1 had surgery at the hospital. Per R1s file review, on 7/31/22, R1 had redness on buttocks, however, the facility did not address or document R1’s pressure injuries on R1’s care plan and R1 had not been admitted to hospice or R1 had not undergone a hospice evaluation. The facility had contacted a hospice nurse to schedule an evaluation of R1, however, R1 was not evaluated by Hospice until around 08/06/22 or 08/07/22. Thus, R1 developed a prohibited health condition, a stage IV pressure injury to the Sacro-Coccyx area, which was unstageable. Therefore, staff retained R1 with a prohibited health condition and failed to ensure R1 pressure wound was treated by a licensed medical professional. (-continued in LIC 9099C-) ***This report serves as an amendment and supersedes the complaint investigation report dated 03/07/24. The purpose of the visit is to correct the deficiency page. The findings remain as Substantiated. *** Regarding allegation: resident was diagnosed with sepsis and E-Coli. It was alleged that R1 had sepsis and E-Coli while in care. The department reviewed R1’s hospital records. On 08/05/22, R1 was sent to for evaluation at a local hospital due to R1 being hot to the touch and having a fever. Upon admission to the hospital, R1’s medical records and lab results indicated R1 had severe sepsis and E coli. The facility staff were aware of R1’s mental and health decline over the past four days prior to the hospital admission. However, the staff did not seek and/or provide R1 with immediate medical assistance, despite R1 changes of condition. Therefore, staff failed to obtain medical treatment for R1 who upon admission to the hospital was diagnosed with Sepsis and E Coli. Regarding allegation: staff did not seek medical attention to resident in a timely manner. It was alleged that staff did not provide a resident with medical attention timely. The department interviewed staff. Per staff interviews, on 07/31/22, the facility staff were aware of R1 had was raw on R1’s buttock. On 08/02/22, the staff observed R1’s change of condition. Per staff, R1’s pressure wound/sore on Sacro-Coccyx was observed to be raw and the R1’s pressure wound had opened up. Staff notified R1’s family/authorized representative about the R1’s opened pressure wound/sore. R1 was scheduled to have a hospice evaluation on 08/06/22. However, on 08/05/22, R1 had a severe fever and R1’s wound on the Sacro Coccyx opened up. Staff reported R1’s sore to be equivalent to the size of a quarter coin. As mentioned above, R1 was hot to the touch and the facility staff noted R1’s fever. R1 was physically and mentally declining over the past four days. As a result, on 08/02/22, R1’s had a change of condition, on 08/05/22, R1 was sent to hospital for evaluation and treatment. Upon admission to the hospital, R1’s medical records indicated R1 had sepsis, E-Coli, and stage 4 pressure injury. Per R1’s record review, the R1’s pressure injury was around the size of a basketball and down to the bone. Therefore, staff were aware of R1’s changes of condition on 08/02/22, however, staff neglected to seek timely medical attention for R1 until 08/05/22, upon which R1 required surgery for R1’s pressure wound. (-continued in LIC 9099C-) ***This report serves as an amendment and supersedes the complaint investigation report dated 03/07/24. The purpose of the visit is to correct the deficiency page. The findings remain as Substantiated. *** Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, and Chapter 8), are being cited on the attached LIC 9099D. An immediate $500 civil penalty is being issued during today's visit due to the neglect/lack of care and supervision resulting in resident sustaining a stage IV pressure injuries. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). Exit interview conducted with Staff#4. Appeal Rights was discussed and a copy was given during visitthe state’s words, verbatim · CDSS document, Mar 22, 2024 · control 28-AS-20220908154436

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Mar 25, 2024

(a) Persons who require health services for...shall not be admitted or retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on record review & staff interviews, the licensee retained a resident with a prohibited health condition (Stage 4 pressure injury) who was not on hospice, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 22, 2024

Plan of correction: Licensee/ Administrator agrees to submit a written statement of how this deficiency will be corrected and prevented by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Mar 25, 2024

(a)(8) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:.. (8) To be free from neglect,… This requirement was not met as evidenced by: Based on record review & staff interviews, the licensee did not comply with the section cited above and provide care by medical professional to resident#1 who had stage 4 pressure injuries, sepsis and E-Coli which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 22, 2024

Plan of correction: Licensee/ Administrator agrees (1) to conduct staff training on regulation 87468.2 and provide proper medical care to pressure injuries residents as required. (2) to submit a written statement of how this deficiency will be corrected by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 25, 2024

(a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met by evidence of: Based on interviews and record reviews, Administrator failed to seek timely medical attention for resident#1 when resident sustained stage 4 pressure injuries, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 22, 2024

Plan of correction: Licensee/ Administrator agrees to conduct staff training on regulation 87465, provide proper medical care which includes pressure injuries for residents as required. Licensee agrees to submit a written statement of how this deficiency will be corrected by the POC due date. Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 4/5/24.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tao conducted an unannounced case management visit during the complaint visit 28-AS-20220908154436. LPA met with staff#1 (S1) caregiver at the facility and spoke with Lynn Sasada, Administrator to discuss the purpose of the visit. The purpose of the visit was to check on the Health and Safety of the Residents and facility. LPA toured the physical plant of the facility and staff file reviews. LPA obtained a copy of the staff/resident roster. LPA reviewed resident#1 file and did not observe physician order for oxygen administration on file. Administrator explained R1’s physician report was taken by paramedic on 8/5/22 when resident was sent to hospital. Administrator said no R1’s physician order for oxygen administration or physician report was currently on file. Deficiencies of Health and Safety were observed per Title 22 Regulations Division 6 Chapter 8. Exit interview was conducted with staff and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(1) · Plan of correction due date: Mar 29, 2024

(b)(1)…licensee shall be responsible for...(1) monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders. This requirement was not met as evidenced by: Resident#1 did not have a physician order for oxygen administration on file. Based on file review, Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 22, 2024

Plan of correction: Administrator would obtain a physician order of oxygen administration for resident#1 or provide a statement explaining why Licensee could not obtain a physician order and how to prevent it from happening in the further. Due by POC due date.

Allegation investigated: Facility did not notify resident's responsible party of a serious injury. Facility did not provide resident's records to responsible party.

Licensing Program Analyst (LPA) Angelica Rea conducted a subsequent visit in regard to the above allegations. **The purpose of the visit is to provide additional information not provided on the report dated 12/7/23**. LPA Rea met with Administrator, Flordeliza Sasada. Regarding the allegation that : Facility did not notify resident #1's responsible party of a serious injury. The invesitgation consisted of review of resident #1's file, including facility notes, and interview(s) with Administrator and Staff #1. Resident #1 is no longer residing at the facility, and was not interviewed. Administrator and Staff #1 stated that they were in constant communication with resident #1's responsible party, and provided copies of facility notes, and text messages to show that they did notify resident's responsible party of resident's injury. LPA Rea spoke to resident #1's responsible party on 12/18/23, who stated that she was not notified of resident #1's injury. However, the standard of proof has not been met because the preponderance of the evidence does not demonstrate the facility was in violation of Title 22 regulations and/or did not make a reasonable effort to communicate with the resident’s family member. Unsubstantiated Regarding the allegation that the facility did not provide resident #1's records to responsible party. The investigation consisted of review of resident #1's file, including facility notes, and interview(s) with Administrator and Staff #1. Resident #1 is no longer residing at the facility, and was not interviewed. LPA Rea spoke to Resident #1's responsible party on 12/18/23. Resident #1's reporting party stated that she personally didn't request any records from the facility. Administrator and Staff #1 stated that they provided resident #1's records to authorized parties who requested the records. Although the allegations 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 allegations are UNSUBSTANTIATED. Exit interview was conducted with Ms. Sasada, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20220830151900

Allegation investigated: Resident sustained a stage 4 pressure injury while in care. Resident was diagnosed with sepsis and E-Coli. Staff did not seek medical attention to resident in a timely manner.

On today visit, Licensing Program Analyst (LPA) Tao conducted a subsequent complaint visit met with staff#4, caregiver. The purpose of the visit was to deliver complaint investigation findings and was discussed with Licensee, Tiffancy Sasada, over the phone. On 09/12/22, Licensing Program Analyst (LPA) Tao conducted the initial complaint investigation for the allegations listed above. LPA Tao conducted a health and safety check and toured the facility with Licensee, Flordeliza Sasada. LPA observed the facility was clean and in good repair, had a minimum of one-week nonperishable foods and a minimum of two days of perishable foods, and had operable wash basins, showers/bathtubs, and toilets and LPA did not observe any immediate health and safety concerns. (-continued in LIC 9099C-) Substantiated On 11/18/22, a subsequent tele-visit was conducted by Investigator Brian Slatic, during the visit, Investigator Slatic interviewed staff from staff#1 (S1) to staff #4 (S4) which included Administrator/Licensee; interviewed resident’s representative (RR) from RP1 to RP3; interviewed local law enforcement (P1); obtained resident records from hospital and obtained records from local law enforcement. IB reviewed resident#1 (R1)’s facility file and any related documentation. Regarding allegation: resident sustained a stage 4 pressure injury while in care. It was alleged that due to staff neglect, a resident had a stage 4 pressure injury on resident’s Sacro Coccyx area while in care. During the investigation, the department interviewed staff from S1 to S4, responsible party (RP) from RP1 to RP3, and Whittier Police Department. The department reviewed R1’s facility file and reviewed R1’s hospital records. Per interviews with staff, on 07/31/22, staff #1 observed R1’s buttock area was a little raw. On 08/02/22, staff #1 observed R1s sore opened up and R1’s responsible party was notified. On 08/04/22, staff #1 indicated R1’s coccyx area had skin peeling off and outer area was reddened and staff notified R1’s responsible party. On 08/05/22, staff reported R1’s pressure sore was equivalent to the size of a quarter coin. On the same day, R1 developed a severe fever of 100-degree Fahrenheit and staff notified R1’s responsible party. R1 was sent to hospital for observation and treatment. Upon admission to the hospital, R1 was diagnosed with a Stage 4 pressure ulcer. R1’s sore was as extremely large and required surgery. On 08/07/22, R1 had surgery at the hospital. Per R1s file review, on 7/31/22, R1 had redness on buttocks, however, the facility did not address or document R1’s pressure injuries on R1’s care plan and R1 had not been admitted to hospice or R1 had not undergone a hospice evaluation. The facility had contacted a hospice nurse to schedule an evaluation of R1, however, R1 was not evaluated by Hospice until around 08/06/22 or 08/07/22. Thus, R1 developed a prohibited health condition, a stage IV pressure injury to the Sacro-Coccyx area, which was unstageable. Therefore, staff retained R1 with a prohibited health condition and failed to ensure R1 pressure wound was treated by a licensed medical professional. Regarding allegation: resident was diagnosed with sepsis and E-Coli. It was alleged that R1 had sepsis and E-Coli while in care. The department reviewed R1’s hospital records. On 08/05/22, R1 was sent to for evaluation at a local hospital due to R1 being hot to the touch and having a fever. Upon admission to the hospital, R1’s medical records and lab results indicated R1 had severe sepsis and E coli. The facility staff were aware of R1’s mental and health decline over the past four days prior to the hospital admission. (-continued in LIC 9099C-) However, the staff did not seek and/or provide R1 with immediate medical assistance, despite R1 changes of condition. Therefore, staff failed to obtain medical treatment for R1 who upon admission to the hospital was diagnosed with Sepsis and E Coli. Regarding allegation: staff did not seek medical attention to resident in a timely manner. It was alleged that staff did not provide a resident with medical attention timely. The department interviewed staff. Per staff interviews, on 07/31/22, the facility staff were aware of R1 had was raw on R1’s buttock. On 08/02/22, the staff observed R1’s change of condition. Per staff, R1’s pressure wound/sore on Sacro-Coccyx was observed to be raw and the R1’s pressure wound had opened up. Staff notified R1’s family/authorized representative about the R1’s opened pressure wound/sore. R1 was scheduled to have a hospice evaluation on 08/06/22. However, on 08/05/22, R1 had a severe fever and R1’s wound on the Sacro Coccyx opened up. Staff reported R1’s sore to be equivalent to the size of a quarter coin. As mentioned above, R1 was hot to the touch and the facility staff noted R1’s fever. R1 was physically and mentally declining over the past four days. As a result, on 08/02/22, R1’s had a change of condition, on 08/05/22, R1 was sent to hospital for evaluation and treatment. Upon admission to the hospital, R1’s medical records indicated R1 had sepsis, E-Coli, and stage 4 pressure injury. Per R1’s record review, the R1’s pressure injury was around the size of a basketball and down to the bone. Therefore, staff were aware of R1’s changes of condition on 08/02/22, however, staff neglected to seek timely medical attention for R1 until 08/05/22, upon which R1 required surgery for R1’s pressure wound. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, and Chapter 8), are being cited on the attached LIC 9099D. An immediate $500 civil penalty is being issued during today's visit due to the neglect/lack of care and supervision resulting in resident sustaining a stage IV pressure injuries, sepsis, and E-coli. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). Exit interview conducted with Staff#4. Appeal Rights was discussed and a copy was given during visit.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 28-AS-20220908154436

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87631(a)(3)(B) · Plan of correction due date: Mar 8, 2024

Healing Wounds (a)(3)(B) All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file. This requirement was not met as evidenced by: Based on record review & staff interviews, the licensee did not: (1) comply with the section cited above; (2) document or update resident#1's Plan of Care; (3) provide care by medical professional to resident#1 who had stage 4 pressure injuries, sepsis and E-Coli which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 7, 2024

Plan of correction: Licensee/ Administrator agrees to conduct staff training on regulation 87631 and resident care plan. Licensee agrees to submit a written statement of how this deficiency will be corrected and prevented by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 8, 2024

Incidental Medical and Dental Care (a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met by evidence of: Based on interviews and record reviews, Administrator failed to seek timely medical attention for resident#1 when resident sustained stage 4 pressure injuries, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 7, 2024

Plan of correction: Licensee/ Administrator agrees to conduct staff training on regulation 87465, provide proper medical care which includes pressure injuries for residents as required. Licensee agrees to submit a written statement of how this deficiency will be corrected by the POC due date. Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by a week after the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Flordeliza Sasada. The following12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was not observed but requested Physical Plant/Environment Safety: The facility is located in a residential area which contains: Living room, kitchen, dining area, 4 Resident bedrooms, 2 bathrooms, laundry area and a detached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Cleaning supplies and toxic substances are inaccessible. Water temperature readings measured within title 22 regulations. Operational Requirements: A current Plan of Operation observed. FACILITY IS CLEARED FOR 6 AMBULATORY OR NON-AMBULATORY RESIDENTS. BEDRIDDEN FIRE CLEARANCE APPROVED FOR BEDROOM #3. HOSPICE WAIVER GRANTED FOR 1 Personnel Records - Staff Training: Administrator on file is current Staff have criminal background clearances. Four (4) staff files were reviewed. Continued on LIC 809-C Staffing: Sufficient staff observed during visit Resident Records - Incident Reports: A total of six (6) resident files were reviewed. Required documents observed on file Resident Rights - Information Required postings observed Food Service: Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for clients to use and to store their meals No cleaning supplies stored near food Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Incident Medical and Dental: First Aid Kid observed (6) of (6) Resident medications reviewed Disaster Preparedness: Emergency and Disaster Plan observed Residents with Special Health Needs: Currently (1) resident receiving hospice services. Hospice care plans observed Inspection Tool was completed and no Title 22 deficiencies are being cited on todays visit. Exit interview conducted and a copy of this report was providedthe state’s words, verbatim · CDSS document, Feb 13, 2024

Allegation investigated: Facility did not notify resident's responsible party of a serious injury. Facility did not provide resident's records to responsible party.

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Administrator, Flordeliza Sasada who assisted with today's visit. Regarding the allegation that : Facility did not notify resident #1's responsible party of a serious injury. The invesitgation consisted of review of resident #1's file, including facility notes, and interview(s) with Administrator and Staff #1. Resident #1 is no longer residing at the facility, and was not interviewed. Attempts were made to interview resident #1's responsible party. However, LPA was unable to interview resident #1's responsible party. Administrator and Staff #1 stated that they were in constant communication with resident #1's responsible party, and provided facility notes, and text messages to show that they did notify resident's responsible party of resident's injury. Regarding the allegation that the Facility did not provide resident #1's records to responsible party. The invesitgation consisted of review of resident #1's file, including facility notes, and interview(s) with Administrator and Staff #1. Resident #1 is no longer residing at the facility, and was not interviewed. Unsubstantiated Attempts were made to interview resident #1's responsible party. However, LPA was unable to interview resident #1's responsible party. Administrator and Staff #1 stated that they provided resident #1's records to resident #1's responsible party. Although the allegations 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 allegations are UNSUBSTANTIATED. Exit interview was conducted with Ms. Sasada, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 28-AS-20220830151900