Golden Eden II

Allegation investigated: Resident sustained multiple falls in care. Facility staff failed to meet residents hygiene needs.

On 07/27/23, Licensing Program Analyst (LPA), Perry Scott initiated a 10-day complaint investigation at the facility listed above. LPA Scott met with Karla Stein, Administrator, and explained the purpose of today’s visit was to investigate the allegations listed above. On 07/27/23, the investigation consisted of the following: During today's visit LPA conducted interviews with the staff (S1- S2), residents were in quarantine and could not be interviewed. LPA requested and obtained copies of the following documents: Resident and staff roster, Id/Emergency Information, pre-placement appraisal, admission agreement, physicians report, and resident appraisal for resident (R1). The investigation revealed the following: Regarding allegation #1: Resident sustained multiple falls in care. Report continued on LIC9099-C Unsubstantiated On 07/27/23, LPA interviewed S1-S2. 2 of 2 staff denied the allegation that Resident sustained multiple falls in care. Both staff confirmed that R1 has never fallen at this facility before. This was the first time that R1 had fallen out of bed. S1 stated that R1 was placed in the bed with secure railings, that was set up with motion sensors. But somehow R1 fell out of bed. LPA verified that an incident report was sent to CCLD. R1-R5 could not be interviewed due to cognitive difficulties. Based on interviews, and records reviewed there is insufficient evidence to support the allegation: Resident sustained multiple falls in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #2: Facility staff failed to meet residents’ hygiene needs. On 07/27/23, LPA interviewed S1-S2. 2 of 2 staff denied the allegation that Facility staff failed to meet residents’ hygiene needs. Both staff confirmed that all residents’ hygiene needs are being performed daily. S2 stated, “We make sure that the residents’ personal hygiene needs are taken care of daily. We make sure that they are bathed, dressed properly, and that when they use the restroom, they’re hands are washed and cleaned. As well as brushing their teeth”. R1-R5 could not be interviewed due to cognitive difficulties. Based on interviews and observations, there is insufficient evidence to support the allegation: Facility staff failed to meet residents’ hygiene needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a hard copy of this report was provided to Karla Stein, Administrator.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 11-AS-20230719163702

Type of visit: Required - 1 Year

On 08/19/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met administrator Karla Stein and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory elderly adults ages 60 and above. Currently, the facility has (1) hospice resident in care. The facility is approved for (2) hospice resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) residents' rooms, (2) bathrooms, (1) staff room, (1) staff bathroom, a living area, a dining area, a kitchen, an outside seating area and a garage. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.8 degrees F. A comfortable temperature of 75 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Two fire extinguishers were charged. A review of the Medication Records Administration (MAR) was observed to be maintained in order and complete. (Evaluation Report continues LIC 809-C) During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire and earthquake drills were conducted on 07/14/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 09/17/22 through 09/17/23. The facility is current on CCL license annual dues. An audit of residents #1-#5 (R1-R5) service files and staff #1-#6 (S1-S6) personnel files revealed to be complete. Interviews were conducted with (3) residents and (1) staff. The facility has the current administrator's certification on file for Mart H Pamintuan #6019786740 Expiration 05/23/2024. LIC 9120 Advisory was provided. No deficiencies during this inspection visit. An exit interview was conducted with Karla Stein and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 19, 2023

Allegation investigated: Staff are not changing residents diaper timely. Staff live in garage. Staff took away resident's call pendant. Administrator did not do a proper rent increase.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Administrator (A1: Karla Stein). LPA/RA conducted a risk assessment prior to entering facility. A1 informed LPA/RA that the facility has no COVID cases nor do the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day visit was conducted by LPA Martessa Brown on 03/02/23 who was met by Administrator (A1: Karla Stein). During today’s visit, LPA/RA Elizabeth Ceniceros re-interviewed Staff #4 (S4: Caregiver – A.M) and Resident #6 (R6: Room #1). LPA/RA interviewed Witness #1 (W1: former R5’s Responsible Person) via landline and Witness #2 (W2: new Resident #5’s (R5) Responsible Person). (Former) Resident #1 was not interviewed during the initial 10-Day visit by LPA as the resident had already moved out of the facility on 10/06/22. LPA/RA did not interview Resident #4 (R4) during this visit as the resident was currently in the hospital. Unsubstantiated LPA/RA toured the facility’s physical plant which included the garage (photos). LPA/RA reviewed the following documents: Staff & Residents rosters, Admission Agreement, Physician’s Report, and Weekly Resident Care Schedule (from 01/23/23 to 02/26/23) for (former) Resident #1. Regarding Allegation #2: this investigation revealed a review of (former) Resident #1’s “Weekly Resident Care Schedule” (from 01/23/23 to 02/26/23) an observation of frequent diaper changes were documented (between 12:00 a.m. – 6:00 a.m., 6:00 a.m. – 9:00 a.m., 9:00 a.m. – 12:00 Noon, 12:00 Noon – 3:00 p.m., 3:00 p.m. – 6:00 p.m., and 6:00 p.m. to 12:00 a.m.) Monday thru Friday for (former) Resident #1. Interviews conducted of facility staff corroborated that they had not received complaints from the residents and/or their responsible person/family member that staff were not changing their loved one’s diapers in a timely manner. Interviews conducted of two (2) residents corroborated that they did not have an issue with facility staff changing their diapers in a timely manner. Interviews conducted of Witness #1 and Witness #2 corroborated that they did not have concerns with facility staff not changing their loved one’s diapers in a timely manner as the witnesses would frequently visit their loved ones and not observe them to have a soiled diaper. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff are not changing residents’ diaper timely is found to be UNSUBSTANTIATED. Regarding Allegation #3: this investigation revealed that LPA Martessa Brown conducted a a tour of the facility’s physical plant during the initial 10-Day visit. LPA/RA Elizabeth Ceniceros conducted a physical tour of the facility’s garage during the subsequent visit (photos). The garage is set up with a table and four (4) chairs, refrigerator, microwave, and a sofa for staffing lounge and break room. Interviews conducted of facility staff corroborated that they use the garage as a break room or employee’s lounge. Administrator indicated that the facility has an extra room for a “live-in” caregiver(s) that is currently occupied by Staff #5 (Caregiver) who works as the NOC caregiver for the facility. Interviews conducted of two (2) residents corroborated that they were not aware of facility staff living in the garage. Interviews conducted of Witness #1 and Witness #2 corroborated that they never saw or were aware of facility staff living in the facility’s garage. A review of the facility’s floor plan documents that the extra room is identified as a “caregiver room”. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Staff live in garage is found to be UNSUBSTANTIATED. Regarding Allegation #4: this investigation revealed based on LPA Martessa Brown’s observation during the 10-Day visit and LPA/RA Elizabeth Ceniceros’ subsequent visit, residents were observed to be wearing their call pendants or have it on their person. Interviews conducted of facility staff corroborated that they have never observed a staff member take away a resident’s call pendant nor received a complaint from a resident and/or their responsible person/family member that the residents’ call pendant was taken away. Interviews conducted of two (2) residents corroborated that they have not had their call pendants removed by a staff member nor observed facility staff take away a resident’s call pendant. Interviews conducted of Witness #1 and Witness #2 corroborated that they did not have issues or observe a staff member take away their loved ones or other resident’s call pendant. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff took away resident’s call pendant is found to be UNSUBSTANTIATED. Regarding Allegation #5: this investigation revealed that (former) Resident #1 was in Room #1 (with a bathroom) when the resident moved into the facility on 06/22/2022. Resident #1 was diaper dependent and did not utilize their bathroom. Administrator stated that the resident’s rent was going to be increased and in order to keep the resident’s rent at the same cost (without increasing), (former) Resident #1 would be moved to Room #6 (without a bathroom); and, it would be the equal amount of what they were paying for Room #1 (with a bathroom). Administrator offered an option to (former) Resident #1’s Responsible Person to save them money - when the increase of rent came around - to move the resident into Room #6 (without a bathroom); and, they would still pay the same amount of rent. The resident did move into Room #6 prior to moving out of the facility on 10/06/22. A review of the (former) Resident #1’s “Admission Agreement” (dated 10/06/22) documented the “Rate for Basic Services” monthly fee for room and basic services was in the amount of Six-thousand Dollars ($6,000) and there was no amended “Admission Agreement” for a rate increase of basic services. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of ADMISSION AGREEMENT: Administrator did not do a proper rent increase is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to Administrator (Karla Stein).the state’s words, verbatim · CDSS document, Aug 16, 2023 · control 11-AS-20230223150413

Allegation investigated: Illegal Eviction

On 3/2/23, Licensing Program Analyst (LPA) Martessa Brown conducted an initial complaint visit to the above facility and investigate the above allegations. LPA conducted Covid-19 risk assessment before entering the building and no Covid-cases. LPA met with Karla Stein, the Administrator and the purpose of the visit was explained. The investigation consisted of the following: On 3/2/23 LPA Brown toured the physical plant with the administrator. LPA Interviewed owner Mart Pamintuan, staff S2-S4, and residents R2-R3, LPA did not interview R1 due to resident had already left the facility. LPA attempted to interview R4 and other residents were unable to interview. LPA obtained and reviewed the following records LIC 500 and Resident roster, R1 emergency contact, Admission Agreement, physician report, weekly resident care schedule and eviction notice and other documentation. The investigation revealed the following: Substantiated Allegation: Illegal eviction It was alleged that the Administrator sent an e-mail stating they were evicting the resident because the Administrator did not have the "manpower" to take care of Resident #1 and the e-mail had no end date. LPA conducted an interview with the owner Mart Pamintuan, Residents #2 - #3 (R2 - R3), attempted interview with Resident #4 (R4), and no interview with Resident #1 (R1) as the resident moved out on 10/06/22. Based on residents' interviews two out of four residents stated staff were having issues with being able to change R1 due to Resident #1's weight and would need two (2) people in order to reposition the resident. During interview, Owner Pamintuan and Administrator Stein stated staff would not want to come to work. As a result, the owner e-mailed an Eviction Notice on 02/04/23 to R1’s family members. During interview, Owner Pamintuan was aware of a 30-day eviction protocol and did not include an end date and reappraisal. LPA reviewed the Eviction Notice letter that stated the facility was unable to keep R1 due to manpower; and, they will need to find another location. Based on documentation obtained there is sufficient evidence to support the above allegation of illegal eviction, therefore the allegation is substantiated. Based on LPA observations and interviews and records review, 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. Exit interview conducted, appeal rights were explained, and a copy of this report was provided to Administrator, Karla Stein.the state’s words, verbatim · CDSS document, Mar 2, 2023 · control 11-AS-20230223150413

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(4) · Plan of correction due date: Mar 9, 2023

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required ..(4)If, after admission, it is determined that the resident has a need not previously identified and a reappraisal.. This requirement was not met as evidence by: Based on observation and interviews conducted, Licensee did not ensure R1 had a reappraisal perform to identify R1's needs before eviction.the state’s words, verbatim · CDSS document, Mar 2, 2023

Plan of correction: Facility will review to submit proof that they understood Title 22 section 87224(a)(4) and a plan on how they will follow eviction procedure by due date to LPA Brown.

Type of visit: Prelicensing

On 7/5/2022 Licensing Program Analyst (LPA’s) Antonia Alvizar and Stephanie Cifuentes conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Today’s pre-licensing evaluation was conducted with applicant Mart Pamintuan. On 2/28/2022 an initial application was received for a Residential Care Facility for the Elderly. The requested capacity is for 6 residents facility has a fire clearance for 6 non-ambulatory residents only. Structure: Facility is a 6-resident bedroom, 3- bathrooms, 1 one-story house with a 1 car attached garage and an outdoor shaded area in the back yard. The resident bedrooms are spacious and easily accommodate the resident's furnishings. There is a shaded back patio which contains a table and 6 chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: All six bedrooms have one bed, one chair, one nightstand, overhead lighting, closets, and dressers. All drawers comply with the requirement of 8 cubic feet of space. There was one designated staff bedroom observed. Bathrooms: All 3 bathrooms have working toilets, wash basins and shower/bathtub. There are grab rails next to both toilets and showers. The tile in bathrooms are made from noon skid material. LPA observed adequate lighting in hallway leading to bathrooms via nightlights. Continued on 809c Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillowcases, hand towels, bath towels and wash clothes where observed stored in bathroom cabinet and hallway closet. Emergency Phone Numbers, Exit Plan & Menu: The telephone system has a land line which was called by LPA and is operational. Emergency Disaster Plan and "See something, Say something, Let Us Know" posted & readily available for review on the wall in front entry. Two fully charged fire extinguishers were found in the facility, one mounted in bedroom hallway and one in the living room. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet next to kitchen sink. Food supply was adequately stored in kitchen refrigerator and cabinets and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items. Smoke Detectors: 12 dual carbon/smoke detectors are present in the facility. All were tested and are fully operational. Appliances: Oven, stove, microwave, dish washer, washer, and dryer working. There are 2 refrigerators, one in the kitchen and one in the garages. Refrigerator and freezer are at the correct temperature for food storage. The residence is equipped with central heat and air. Toxins: Locked/stored in cabinet in laundry area. Medications, First-Aid Kit & Book: Area for medication storage was inspected, they will be kept in a locked kitchen cabinet. Area for records was inspected, they will be stored in locked file cabinet present in living room. First aid kit, located in a locked cupboard in kitchen area, was inspected which has at least the following: thermometer, tweezer, scissor, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to residents. Continued on 809c Residents & Staff Files: Records of staff and residents shall be stored in a file cabinet in living room, section has been inspected along with the available records present. Reading Material, Games, Equipment & Materials: The facility has board games, puzzles, playing cards, and other recreational materials for the resident's use. Pool/Jacuzzi & Pets: LPA's did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 5/12/2022 for 6 non-ambulatory residents with no special instructions. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Component III: Conducted at the Pre-Licensing visit, on 7/5/2022 at Golden Eden II, information provided about how to operate the facility within substantial compliance. . An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant.the state’s words, verbatim · CDSS document, Jul 5, 2022

Type of visit: Office

Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): NO Method: Telephone call with CAB COMP II Participants: MART HYSAM PAMINTUAN Applicant/administrator Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. 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 property 8. Discussed the COVID-19 Mitigation Plan & PIN emailedthe state’s words, verbatim · CDSS document, Jun 6, 2022