Pepper Tree Assisted Living

Type of visit: Required - 1 Year

On 11/17/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with caregiver Miguel Can and was later joined by Licensee Stephanie Klein and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly residents ages 60 and above. The facility is approved for six (6) non-ambulatory residents of which and may retain four (4) hospice. The facility is a single-story structure located in a residential neighborhood. The facility consists of the following: five (5) resident's rooms, four (4) bathrooms, a living room area, dining area and kitchen. There is a detached garage located next to the facility used for a staff break room and for storage only. The washer and dryer are located in the garage. There is a patio area in front of the garage with shade and ample seating. There is also a patio area in the backyard with shade and ample seating for the residents. LPA and caregiver toured the physical plant. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature met Title 22 requirements in the kitchen and bathrooms and measured between 106.0 F and 110.5 F. A comfortable temperature was maintained in the facility. Evaluation Report Continues on LIC 809-C. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies and toxins were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. There was one (1) fire extinguisher fully charged located in the kitchen area. First aid kit was available in the pantry area. Smoke alarms and carbon monoxide detectors were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed six (6) residents, one (1) staff and private caregivers present during the tour. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE) with most of the PPE located in the garage. All mandated inspection control posters were posted. Advisory Notes – One (1) Technical Assistance were issued, please see LIC9102-AN. There were no deficiencies cited during this inspection visit. An exit interview was conducted and a copy of this report was provided to Licensee Stephanie Klein.the state’s words, verbatim · CDSS document, Nov 17, 2022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 07/15/2022, Licensing Program Analyst (LPA) Don Senaha conducted a Case Management visit to check on the health and safety of the residents living at the facility. LPA was met with Licensee Stephanie Klien and explained the purpose of the visit. LPA toured the physical plant with caregivers Princess Diaz and Miguel Can. There was a deficiency and civil penalty assessed for fingerprint clearance. See LIC 809-D page. An exit interview was conducted with Licensee Stephanie Klien a hard copy was provided for signature.the state’s words, verbatim · CDSS document, Jul 15, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Jul 15, 2022

87355 (e) Criminal Record ClearanceAll individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility. (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: During the visit conducted on 07/15/22, LPA observed and verified that (S1) Princess Diaz and staff (S2) Miguel Can was employed and worked at this facility prior to obtaining a California clearance or a criminal record exemption as required by the CCLD.the state’s words, verbatim · CDSS document, Jul 15, 2022

Plan of correction: Licensee will adhere to Title 22 Section 87355. Staff (S1-S2) will not return to work until they have obtained a California clearance, or a criminal record exemption as required by the CCLD by POC 07/16/22. A civil penalty in the amount of $100.00 was issued for S1. A civil penalty in the amount of $500 was issued for S2. Citation was cleared during visit 07/15//22.

Allegation investigated: Staff did not reposition resident Staff did not change diapers timely Staff did not bathe resident Resident sustained a pressure injury while in care Staff did not administer medications to resident Staff did not change residents bedding

THIS REPORT SUPERSEDES REPORT DATED 03/11/2022. TO AMEND REPORT. Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Mila Santos, the facility house manager. The investigation consisted of following: Interviews and Record reviews. On 11/19/2021, LPA interviewed S#1, R#2, & R#3. On 03/07/2022, LPA interviewed Administrator and S#2. LPA requested and received the following documents: Face sheets, Pre-Appraisals, Physician's Report, Medical Notes, and Hospice notes dated 11/01/21, for R#1. Based on the LPA's investigation, the investigation revealed the following. For Allegation 1 - Staff did not reposition resident. Interviews with Administrator, S#1, & S#2, stated that Silverado hospice would take care of repositioning for R#1. The staff only assisted when requested by Hospice nurses. Unsubstantiated The facility spoke with hospice about taking care of R1, hospice advised the facility that they would take care of R1 and the facility could assist them when hospice nurses needed or requested help and/or assistance. Hospice nurses were taking care of R#1 24/7, R#1 had continuous care. R#1 always had around the clock nurse taking care of R#1 and facility staff available when needed. The family hired an additional care giver for R1 to assist hospice with R1. Interviews with R#2 & R#3 stated that they did not need repositioning, but the staff there are great. They help them with all their needs. LPA reviewed hospice notes and facility care plan revealed that the repositioning of R#1 was done by the hospice nurses and staff would help at times, when requested and needed and would check in on R1 every 2/3 hours. The interviews conducted and records reviewed did not concur with the above allegation. Allegation 2 - Staff did not change diapers timely. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice advised the facility staff that R1did not need R1’s diapers changed since R#1 had G-tube, so there was no need to change the diapers. Staff spoke with Silverado hospice and explained the even though R#1 had a G-tube R#1 still required to have the diaper checked and change if needed. Facility staff would go to check R1 to see if R1 needed a diaper change and/or see if Hospice needed their help. Interviews with R#2 stated R#2 does not need diapers, R#2 goes to the bathroom on her own. R#3 stated the staff only changes R#3 diapers at night in morning R#3 goes to the bathroom on her own. They never leave R#3 in a soiled diaper. LPA Soto reviewed hospice notes they revealed that they were changing R#1 diapers every 3 hrs. when and if needed and would check in on R1 every 2/3 hours. R#1 always had around the clock nurse taking care of R#1 and facility staff available when needed. The family hired an additional care giver for R1 to assist hospice with R1. Interviews conducted and records reviewed did not concur with the above allegation. Allegation 3 - Staff did not bathe resident. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice would take care of bathing R#1. Hospice would give R#1 sponge bath every morning. Facility staff would wash R#1 hair to help hospice nurses. Interviews with R#2, stated that R#2 bathes themselves. R#3 stated that the staff bathes R#3 3x a week, they are very good about that. LPA Soto reviewed hospice notes dated 11/01/21, they revealed that Silverado hospice was bathing R#1 every morning. R#1 always had around the clock nurse taking care of R#1 and facility staff available when needed and would check in on R1 every 2/3 hours. The family hired an additional care giver for R1 to assist hospice with R1. Interviews conducted and records reviewed did not concur with the above allegation. Allegation 4 - Resident sustained a pressure injury while in care. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice noted dated 11/01/21, that R#1 returned from hospital with the pressure injury. Silverado hospice noted it on their assessment the first day R#1 arrived. Interviews with R#2 & R#3, stated that they have never had pressure injuries, so they do not know anything about that. LPA Soto reviewed hospice notes, they revealed that Silverado hospice did note on their assessment of R#1, R#1 had the pressure injury when R#1 returned from hospital. The wound was cleaned and medicated every 2 hours. R#1 always had around the clock nurse taking care of R#1 and facility staff available when needed and would check in on R1 every 2/3 hours. The family hired an additional care giver for R1 to assist hospice with R1. Interviews conducted and records reviewed did not concur with the above allegation. Allegation 5 - Staff did not administer medications to resident. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice gave R#1 all their medication. Interviews with R#2 & R#3, stated that they always get their medication on time, staff has never forgotten to give them their medication. LPA Soto reviewed hospice notes dated 11/01/21, they revealed that Silverado hospice handled R#1 medication. Facility staff did not administer R#1 medications, but they were available for any help or assistance. Interviews conducted and records reviewed did not concur with the above allegation. Allegation 6 - Staff did not change residents bedding. Interviews with Administrator, S#1, & S#2 stated that they always change the R1’s and other residents bedding. They replaced the bedding 2x a week and when needed due to accidents. Interviews with R#2 & R#3, stated that they always have their bedding changed, at least once a week. Their bedding is always clean. LPA observed R#2 & R#3, bedding they were clean. The interviews and LPA’s observations did not concur with the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated An exit interview was conducted with Mila Santos, House Manager, and a hard copy was provided.the state’s words, verbatim · CDSS document, May 16, 2022 · control 11-AS-20211115092738

Type of visit: POC

Licensing Program Analyst (LPA) conducted an unannounced POC case management visit to the above facility. LPA met with Mila Santos, House Manager and the purpose of the visit was explained. LPA was shown all the medication for R1 with all pharmacy labels, including over the counter medication. LPA cleared there outstanding POC. An exit interview was conducted with Mila Santos, House Manager and copy of report was emailed. Due to technical difficulties.the state’s words, verbatim · CDSS document, Apr 14, 2022

Allegation investigated: Staff did not reposition resident Staff did not change diapers timely Staff did not bathe resident Resident sustained a pressure injury while in care Staff did not administer medications to resident Staff did not change residents bedding

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Mila Santos, the facility house manager. The investigation consisted of following: Interviews and Record reviews. On 11/19/2021, LPA interviewed S#1, R#2, & R#3. On 03/07/2022, LPA interviewed Administrator and S#2. LPA requested and received the following documents: Face sheets, Pre-Appraisals, Physician's Report, Medical Notes, and Hospice notes for R#1. Based on the LPA's investigation, the investigation revealed the following. For Allegation 1 - Staff did not reposition resident. Interviews with Administrator, S#1, & S#2, stated that Silverado hospice would take care of repositioning for R#1. The staff only assisted when requested by Hospice nurses. They would only help when asked to by hospice nurses. Unsubstantiated Hospice nurses were taking care of R#1 24/7, R#1 had continuous care. R#1 always had a around the clock nurse taking care of R#1 and facility staff available when needed. Interviews with R#2 & R#3 stated that they did not need repositioning, but the staff there are great. They help them with all their needs. LPA reviewed hospice notes and facility care plan revealed that the repositioning of R#1 was done by the hospice nurses and staff would help at times, when requested and needed. The interviews conducted and records reviewed did not concur with the above allegation. Allegation 2 - Staff did not change diapers timely. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice did not need them to change diapers. They would change diapers, but since R#1 had G-tube there was no needed to change the diapers. Staff spoke with Silverado hospice and explained the even though R#1 had a g-tube R#1 still required to have the diaper checked and change if needed. Interviews with R#2 stated R#2 does not need diapers, R#2 goes to the bathroom on her own. R#3 stated the staff only changes R#3 diapers at night in morning R#3 goes to the bathroom on her own. They never leave R#3 in a soiled diaper. LPA Soto reviewed hospice notes they revealed that they were changing R#1 diapers every 3 hrs. when needed. Interviews conducted and records reviewed did not concur with the above allegation. Allegation 3 - Staff did not bathe resident. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice would take care of bathing R#1. They would give R#1 sponge bath every morning. Facility staff washed R#1 hair to help hospice nurses. Interviews with R#2, stated that R#2 bates themselves. R#3 stated that the staff bathes R#3 3x a week, they are very good about that. LPA Soto reviewed hospice notes they revealed that Silverado hospice was bathing R#1 every morning. Interviews conducted and records reviewed did not concur with the above allegation. Allegation 4 - Resident sustained a pressure injury while in care. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice noted that R#1 returned from hospital with the pressure injury. Silverado hospice noted it on their assessment the first day R#1 arrived. Interviews with R#2 & R#3, stated that they have never had pressure injuries, so they do not know anything about that. LPA Soto reviewed hospice notes they revealed that Silverado hospice did note on their assessment of R#1, R#1 had the pressure injury when R#1 returned from hospital. Interviews conducted and records reviewed did not concur with the above allegation. Allegation 5 - Staff did not administer medications to resident. Interviews with Administrator, S#1, & S#2 stated that Silverado hospice gave R#1 all their medication. Interviews with R#2 & R#3, stated that they always get their medication on time, staff has never forgotten to give them their medication. LPA Soto reviewed hospice notes they revealed that Silverado hospice handled R#1 medication. Facility staff did not administer R#1 medications. Interviews conducted and records reviewed did not concur with the above allegation. Allegation 6 - Staff did not change residents bedding. Interviews with Administrator, S#1, & S#2 stated that they always change the residents bedding. They replace the bedding 2x a week and when needed due to accidents. Interviews with R#2 & R#3, stated that they always have their bedding changed, at least once a week. Their bedding is always clean. LPA observed R#2 & R#3, bedding they were clean. The interviews and LPA’s observations did not concur with the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated An exit interview was conducted with Mila Santos, House Manager, and a hard copy was provided.the state’s words, verbatim · CDSS document, Mar 11, 2022 · control 11-AS-20211115092738

Type of visit: Required - 1 Year

Licensing Program Analysts Ana Soto and Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPAs met with caregiver staff Mila Santos, House Manager; the facility is clear of Covid-19 infection. LPAs explained the purpose of todays visit. The facility is licensed for six (6) non-ambulatory residents over the age of 60, hospice waiver approved for four (4). LPA and staff toured the inside and outside grounds of the facility. The one story residential house consists of five (5) resident bedrooms, four (4) resident bathrooms, dining area, and kitchen, laundry area in the garage, and a shaded patio area, backyard. During the tour, LPA observed the facility’s infection control practices. LPA verified that the facility has an approved mitigation plan report. LPA observed a sanitizing station outside near the facility entrance; PPE supplies are readily available to staff, and an additional 30-60 day supply of PPE was observed in the garage area. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the shaded backyard or front patio area. LPA observed all staff wear a face covering. LPA observed required postings throughout the facility. Bedrooms were inspected, Beds and bedding supplies were in good condition, adequate lighting provided. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, the water temperature measured at 109.6 degrees F in bathroom. Comfortable temperature was maintained in the facility. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. One (1)Carbon Monoxide and interconnected Smoke Detectors were tested, and in operating condition. The facility has one (1) Fire Extinguisher, which was checked and found to be fully charged and accessible.. The First Aid kit was available and fully stocked. There are no security bars or weapons on the premises. LPA checked staff and resident file and reviewed medication. On 11/19/2021 at approximately 10:42am LPA observed over the counter medication: Calcium, D3, C, Multi-50+ vitamins, aspirin, and allegra for Resident#1 (R1), medication bottles didn’t have prescription label. Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No bodies of water present. Advisory Notes with technical assistance were issued: 1. Ensure all staff are fit tested for respirators. 2. CCLD provider information notices (PINS) shall be posted and available to residents/ staff. 3. Facility shall take and document residents & staff temperature & screen for covid symptoms. 4. Isolation room postings shall be available in the event of a Covid-19 positive case. A deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to facility representative, _Mila Santos.the state’s words, verbatim · CDSS document, Nov 19, 2021

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.