Emerald Isle Assisted Living #2

Type of visit: Required - 1 Year

On 2/9/2023 LPM Eva Alvarez and LPA Alfonso Iniguez conducted an unannounced annual visit. LPM and LPA met with House Manager/Joy Miran and Caregiver/Christina Macasieb. There are currently (5) residents residing in the facility. The facility is licensed to serve (6) elderly residents 59 and over. The faclity is approved to support (5) hospice and (1) bedridden residents. At this time, there is (1) ambulatory, (3) non-ambulatory, and (1) bedridden residents living in this facility. The facility is a single-story structure located in a residential neighborhood. It consists (3) resident bedrooms, (1) staff room, (2) full bathrooms, kitchen, dining area, living room, and patio area with shade located in backyard. The facility entrance and exits are wheelchair accessible. The facility has (1) garage that is utlized for supplies. LPM and LPA observed required posting at the entrance and throughout the facility. The facility smoke detectors and carbon monoxide detectors were tested are operational. The facility has night lights in hallways and restroom #1 has non-skid mats and grab bars. Restroom #2 is under construction due to water damage. The construction does not appear to interfere with residents daily routines or presenting a safety hazzard. LPM and LPA observed a sign-in/sanitation station at the facility entry. Facility has screening process for visitors, sanitizer/soap, paper towels, and additional PPE supplies are stored in the garage. The facility is prepared to provide a private room for isolation if needed. The facility mitigation plan was approved by CCL on 5/16/2021. No citations were issued during this visit. An exit interview was conducted with Chrisina Macasieb and copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA's) Ana Soto and Wendy Gibbs conducted an unannounced Annual required and infection control visit to the above facility. LPA's were met by Joy Miran, House Manager and the purpose of today’s visit was explained. There are currently (5) residents in the facility. (1) residents are ambulatory, (3) are non-ambulatory, (1) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (5) bedrooms, (2) full bathrooms, The facility has 4 mini rams on the outside doors, 1 ramp inside the garage, shaded back porch, front yard, laundry room in the attached 2 car garage. LPA and Joy toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (2) bathrooms that contain; grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors were inter-connected and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is 109.9 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, signs in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) No trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, No fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPhone for residents to use, resident’s temperatures are checked and logged (twice a day). Emergency contacts updated and posted; PPE's are enough for 30 days. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time. Technical Advisories (TA) issued. 1 No trash can w/lid in bathroom 2. No fit testing completed for staff. An exit interview conducted with Joy Miran, House manager and a hard copy of report provided. Due to technical difficulties (printer) LPA will email report.the state’s words, verbatim · CDSS document, Sep 1, 2022

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility did not issue refund to resident's authorized representative

On 03/03/22 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced complaint investigation regarding the allegation above. LPA was greeted by staff Joy, spoke with the Administrator Laura telephonically. The purpose of the visit was explained. Investigation Consisted of: Physical Plant tour, Interview with Administrator, Resident interviews, Record Review of Text messages, Admissions Agreement, Physicians Report, Pre-Appraisal, and Physical Plant Tour. Regarding Allegation: Facility did not issue refund to resident's authorized representative Rp stated the Resident (R1) was brought to facility to reside there on 01/18/22. On the same day, several hours later R1 was sent from facility, to the hospital. R1 was admitted to the hospital for several days, and it was decided later, that R1 would not return back to the facility. RP stated that they were told by Administrator, that a refund check was being issued, but has not yet been received. RP stated that they were told by the Administrator that the mailed check had been returned. Rp told LPA To date, no check has been received. ********** Continued on 9099C********************** Unsubstantiated Interviews with Administrator revealed the room for R1 was held from 01/18/22, until 02/06/22 in which it was informed by the family member, that R1 would not be returning back to facility. A prorated amount of $3450.00 was issued by check, dated 02/09/22 and mailed to the address listed of the Power of Attorney (POA) on 02/10/22. Administrator provided LPA with copies of text messages. LPA observed Text messages between Administrator and Family Member in which the Administrator provided a screens shot of the check, and Invoice as proof of attempted mailed check. LPA compared the address in which the check was mailed, to the address listed for POA, check was mailed as it was listed. LPA observed in text message screen shot, an envelope addressed to the POA with a yellow label dated 02/17/22 indicating “Return to Sender No Such Number, Unavailable to Forward.” Administrator stated that they use a Po box which is listed as the sender and did not see that the check was returned until 02/23/22. Observation of Text messages between Administrator and family member were observed of Administrator asking the family member for a correct address to re issue the check. Administrator stated that they have not received a response from R1’s POA, or Family member for use of a correct address. Administrator stated they are not intentionally trying to withhold refund. Based on LPA Interviews, Record Review, and Observation the Department finds that “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.” An exit interview conducted, and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 3, 2022 · control 11-AS-20220225151411

Type of visit: Case Management - COVID-19

Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced Case Management visit. Upon arrival at the facility, LPA Montoya called the Administrator, Laura Martz and left a voicemail message. Soon later, Martz arrived the facility and assisted LPA Montoya with the visit. LPA Montoya explained the purpose of this visit is to provide technical assistance on Covid-19 protocols due to unavailability of the administrator to assist the department via zoom visit. Martz explained she is busy assisting her four facilities today but she will cancel her errands and will assist LPA Montoya. Based on the assessment and interview with the administrator and staff, the facility has five residents. Two residents were tested positive on 11/25/2021 and the other three residents were tested positive on 11/26/2021. Staff (S1 & S2) were tested negative for consecutive two weeks since the Covid-19 outbreak commenced in the facility. Martz stated S1 & S2 will continue to test for Covid-19 for another week as instructed by the Department of Public Health. Per LPA's review of the personnel report, there are seven (7) staff on the list including the administrator. Martz explained only S1 & S2 have been working since the Covid-19 outbreak at their own discretion. Martz explained she reported the outbreak to the Department of Public Health on 12/1/2021 and not to CCLD. Per record review, CCLD conducted an intake of the Covid-19 outbreak on 12/2/2021 with the administrator. During today's visit, LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA observed a sanitizing station at the facility entrance; visitors log with COVID-19 screening and temperature log, and records of daily COVID-19 screening and temperature checks of residents and staff; vaccination records of staff and residents are kept in the facility; soap, paper and cleaning supplies were ample; and Covid-19 posters were observed. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), a deficiency was observed and is being issued a citation on LIC 809-D. Exit interview was conducted with Administrator, Laura Martz. Due to a technical difficulty, LPA was not able to provide a hard copy of the report after the visit but an electronic copy was emailed to Administrator Martz, Appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 9, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Dec 10, 2021

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: Based on record review and interview, there were two residents tested Covid-19 positive on 11/25/2021 and additional three residents were tested positive. Licensee failed to report this incident within 24 hours. Licensee reported the incident to the Department of Public Health on 12/1/2021 and DPH informed CCLD on 12/2/2021. This poses an immediate health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Licensee informed the department of the Covid-19 outbreak on 12/2/2021. This had been corrected prior to visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(2) · Plan of correction due date: Dec 17, 2021

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidence by: Licensee failed to report a Covid-19 outbreak to the department within 24 hours either by telephone or facsimile to the licensing agency. This poses a potential health, safety and/or personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Licensee shall review the Title 22 of the cited Section and shall self-certify. Licensee shall send a proof of correction to Lourdes.Montoya@dss.ca.gov by the POC due date. n