Santa Fe Home Care II

Type of visit: Required - 1 Year

On 10/20/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced annual visit using the full CAREs tool. LPA met with Caregiver, James Okeuhie, and explained the purpose of today’s visit. The facility is licensed to serve clients aged 60 and over, six non-ambulatory. They have an approved Hospice Waiver for six residents. There are currently 4 residents residing at the facility. Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms, 2 bathrooms, living room, kitchen, dining room, family room, garage, and a shaded area. LPA toured the inside and outside grounds of the facility with staff. All walkways on the side of the facility were clean, clear, and free of obstruction, debris, and hazards. There were no bodies of water observed. Bedrooms All bedrooms were inspected. All rooms have the required furniture including a bed(s), dresser(s), nightstand(s), chair(s), and storage space for residents’ personal belongings. All beds were observed to have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of bed linens in a hall cupboard that were in good repair. All bedrooms were observed to have ample lighting. Bathrooms LPA inspected all bathrooms. Bathrooms were found to be within Title 22 regulations and were clean and operational. All bathrooms had secured handrails, nonskid mats, and a shower chair. LPA observed an ample supply of hygiene products and towels stored in a cupboard in the hall. The water temperature measured 118.3 and 119.2-degrees Fahrenheit. Kitchen LPA inspected the kitchen and found it to be clean and sanitary. All appliances were tested and are in good working condition. LPA observed an ample supply of cutleries, pots, and pans in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All food was properly labeled and stored. The water temperature measured 119.8-degrees Fahrenheit. All sharps were observed in a locked drawer in the kitchen and are inaccessible to residents. LPA observed all cleaning products secured in a locked cabinet under the sink and are inaccessible to residents. Common Rooms LPA inspected all common rooms. LPA observed two couches and activities in the family room for resident use. The living room has 5 recliners for residents. LPA observed a screened fireplace that is inaccessible to residents. The dining room has a large table and chairs to accommodate all residents. LPA will return to complete file review and medication review. An exit interview was conducted with Caregiver, James Okeuhie, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2023

Type of visit: Case Management - Deficiencies

On 09/29/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with House Manager Lucy A. Dezell and explained the purpose of the visit. During an investigation visit on 09/29/23 associated with complaint #11-AS-20230911101639, LPA, was informed that hospice file records for resident #1 (R1) were not available. LPA was informed by administrator Virginia Asis that (R1) was no longer a resident and was uncertain of the date when (R1) was discharged and had to confirm with the business office. The facility did not have discharge paperwork available nor hospice file and Medication Administration Records (MAR) for all residents. The facility did not have available during the investigation visit on 09/14/23 and 09/28/23 a Personnel Report LIC 500 was not provided. Based on the information provided by the administrator, the facility violates the California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D). An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Lucy Denzell.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8706(a) · Plan of correction due date: Oct 10, 2023

87506 Resident Records (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 evidence by: Based on observation and interview, Licensee failed to provide resident records for (R1) hospice records and Medicaiton Administration Record during visits. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: The licensee will ensure records for all residents are current and maintained for each resident in the facility and available to CCL during visits. LIcensee will obtain copies of hospice records and (MAR) for (R1). Proof of correction must be sent by due date 10/10/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(1)(2) · Plan of correction due date: Oct 10, 2023

87405 Administrator - Qualifications and Duties (b) The administrator of a facility.. shall have the responsibility and authority to carry out the policies... (1) Knowledge of the requirements for providing care and supervision... (2) Knowledge of and ability to conform to the applicable laws, rules, and regulations This requirement was not met as evidenced by: Based on observation record and interviews, the Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited. This violation poses/posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee shall read Title 22, Section 87405 “Administrator - Qualifications and Duties” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 10/10/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(e) · Plan of correction due date: Oct 10, 2023

87412 Personnel Records (e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. This requirement is not met as evidence by: Based on observation and interview, Licensee failed to provide personnel report LIC 500 during visits. Uncertain of adequate staff coverage. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: The licensee will ensure records for all residents are current and maintained for each resident in the facility and available to CCL during visits. LIcensee will obtain copies LIC 500. Proof of correction must be sent by due date 10/10/23. This citation was correction during visit. A copy of LIC 500 provided.

Allegation investigated: Staff are not ensuring that resident receives medications as prescribed by their physician.

On 09/28/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit. LPA was greeted by caregiver Allan Gloriani. Gloriani contacted Virgina Asis who later was present during the visit. LPA explained the purpose of today's visit is gather information for the allegations mentioned above. The investigation consisted of the following: LPA obtained copies of the roster for residents and staff. Service records for resident #1 (R1), and other pertinent documents associated with this complaint. Interviews with staff #1-#3 (S1-S3), residents #2-#5 (R2-R5), and witnesses #1 - 3 (W1-W3). A tour of the physical plant was conducted. Evaluation Report continues LIC 9099-C Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #6: Staff are not ensuring that resident receives medications as prescribed by their physician. The details of the complaint alleged that resident #1 (R1) may not be receiving medications as prescribed by the physician. The complainant reported due to (R1's) health condition it is suspected the doctor's prescribed medication orders are not being followed by staff. Service records revealed (R1) was admitted at Santa Fe Home Care II on 08/23/22 and was discharged on 09/18/23 according to administrator staff #1 (S1). (R1) was on hospice care and was being provided hospice care services twice a week. Pacific Post Acute Medical Records (dated: 08/23/22) listed (R1) was on (12) prescription medications. An interview between 10:01 am - 10:49 am with (2) out of (2) staff #2-#3 (S2-S3) confirmed that not knowing what a Medication Administrator Record (MAR) is for (R1). (S2) admitted that no medications were documented when administered to residents. (S2) confirmed that hospice did not assist with (R1's) medications and that only the staff at Santa Fe Home assisted. An interview with (S1) confirmed that staff assisted with medications for the residents and that the facility has a (MAR) on record but was unable to produce the records for the Department for review. The Department interviewed residents between 09:02 am - 12:00 pm (2) out (5) residents handled their medications residents #2 and #5 (R2 and R5). Three residents required assistance with medications residents #1, #3, and #4 (R1, R3, and R4). Physician's Report for (R1) (dated 08/05/22) indicated (R1) is not able to manage own prescription medications or able to administer own PRN medications. An interview with (R1) was conducted on 09/15/23, however, due to (R1's) health condition (R1) was not able to hold a conversation. The facility was not able to produce evidence of hospice records, resident's progress notes or (MAR) when requested. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Virginia Asis, Administrator, and a hard copy of the report along with appeal rights.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 11-AS-20230911101639

From the deficiency page — Deficiency type: Type A · Section cited: CCR 98465(c)(2) · Plan of correction due date: Sep 29, 2023

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need .. medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on interviews, the licensee did not comply with this section. Licensee did not have evidence to show proof that prescribed medications or PRN for (R1,R3 & R4) were administered PCP orders. This poses an immediate health, safety or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Licensee shall ensure medications are administered according to PCP orders with proof of documentation. Licensee will obtain a copy of documentation noting medications were disbursed properly per PCP orders. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 09/29/23. This was corrected during Case Management visit on 09/29/30.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 10, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on interviews, the licensee did not comply with this section. Staff assisted with medications for residents without knowledge of documenting PRN or prescribed medications. Residents are not provided a safe environment. This a potential health, safety or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Licensee shall ensure medications are administered according to PCP orders and that staff a trained on administering medications. The facilty will conduct a training on medications with staff. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 10/10/23.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are not ensuring that facility is free of pests. Staff are not following safe food handling practices. Facility has expired food.

On 09/14/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial complaint visit. LPA was greeted by House Manager Lucy Dezell. Dezell contacted Virgina Asis who later was present during the visit LPA explained the purpose of today's visit is gather information for the allegations mentioned above. The investigation consisted of the following: LPA obtained copies of the roster for residents and staff. Service records for resident #1 (R1), and other pertinent documents associated with this complaint. Photographs were taken during the plant inspection of the faciltiy. Evaluation Report continues LIC 9099-C Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff are not ensuring that facility is free of pests. The details of the complaint alleged the facility does not ensure the residential home is free from pests. The complainant reported that pests were observed in the kitchen and resident rooms. On 09/14/23 between 9:00 am -11:00 am, the Department conducted a plant inspection of the entire residential home. The Department observed ants inside the refrigerator at 9:57 a.m. Additional pests were identified outside the perimeter of the refrigerator along with residue of dead ants or pest droppings. Flies were observed around the kitchen sink area. The Department inspected each resident's room, bathrooms, activity room, dining area, outside patio area, and garage and did not observe any pests in these spaces. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Allegation #2: Staff are not following safe food handling practices. Allegation #3: Facility has expired food. In the complaint, the facility is alleged to not handle food in a safe manner. The complainant reported food is left on kitchen counters that are improperly stored and is retaining expired food items. On 9/14/23 between 9:00 am - 11:00 am, the Department identified (10) food items with expired dates stored inside the refrigerator and food pantry. The following were identified with expired dates:(1) Creamy Peanut Butter, (1) Furman Spaghetti Can Sauce, (1) Kraft Thousand Island Dressing, (1) Daisy Sour Cream, (1) Mustard Spread, (1) Zito Salad Dressing, (1) Ragu Spaghetti Bottle Sauce, (1) Ensure Plus, (1) I Can Not Believe It's Not Butter, and (1) Crema Mexicana Table Cream. The Department observed unsafe practices in handling food items for residents contained in the refrigerator and inside the food pantry. These food items were not stored properly to prevent harmful bacteria, viruses, parasites, contamination or chemical substances. (Evaluation Report continues LIC 9099-C) An uncovered gelled Jello with no plastic wrap was stored in the refrigerator, (2) celery heads not completely wrapped in foil or stored in a plastic seal bag in the refrigerator crisper, and (3) opened box cereals were not stored in air-tight containers. Based on the information gathered, there is sufficient evidence to support the allegations mentioned above. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit interview was conducted with Virginia Asis, Administrator and a hard copy of the report along with appeal rights. *Immediate Civil Penalties Issued* Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *the state’s words, verbatim · CDSS document, Sep 14, 2023 · control 11-AS-20230911101639

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 28, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on observation, the licensee did not comply with this section. LPA observed ants, pest droppings, dead pest inside the refrigerator and the outside perimeter of the appliance. This poses a potentieal health, safety or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 14, 2023

Plan of correction: Licensee shall ensure all spaces in the residential facilty clean, sanitary and safe free from pest at all time. Licensee will obtain for pest control to spray interior and exterior of the facility. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 10/10/23 *Civil Penalty - Repeat Violation*

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Sep 28, 2023

87555 General Food Service Requirements (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidence by: Based on observation, the licensee did not comply with this section. LPA observed (10) food items that had expired dates. This poses a potentieal health, safety or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 14, 2023

Plan of correction: Licensee shall discard all expired food and shall ensure the facility does not serve expired food to residnents. Licensee shall read Section 87555 and shall provide an in-service training to all staff. Proof of correciton must be faxt to 323-981-1781 attn: LPA Dabuet by 10/10/23. *Civil Penalty - Repeat Violation*

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9)(28) · Plan of correction due date: Sep 28, 2023

87555 General Food Service Requirements (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. (28) All food shall be protected against contamination... This requirement is not met as evidence: Based on observation, LPA identified unsafe practices of food items not stored properly in refridgerator and pantry free from contamination, harmful bacteria, viruses, parasites, or chemical substances. This poses a potential health, safety and/or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 14, 2023

Plan of correction: LIcensee will adhere to Section 87555 and ensure that all food items are handled safely, and stored in food storage containers for preparation and service. Licensee will read provide an in-serice training to all staff. Proof of correction must be sent by fax to 323-981-1781 attn: LPA Dabuet by 10/10/23.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not follow safe food handling practices, Staff did not keep resident's information confidential.

On 5/4/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced subsequent complaint visit at this facility to obtain additional information and to deliver complaint findings. LPA was greeted by Caregiver Allen Gloriani and House Manager/Caregiver Lucy Dezell. Administrator Virginia Asis arrived later and joined the visit. LPA explained the purpose of the visit. The investigation consists of the following: On 5/3/2023, LPA obtained copies of the facility roster for residents and staff. Interviews were conducted with three staff (S1-S3) and four residents (R2-R5). LPA was unable to obtain information from two residents (R6-R7) due R6’s medical condition and R7 is in the hospital. LPA obtained and reviewed R1's service records. A tour of the facility was conducted. On 5/4/2023, LPA interviewed one resident (R1) and one witness (W1) by telephone. However, LPA Montoya was unsuccessful in attempt to conduct telephone interview with one potential witness (W2). Report continued in LIC 9099C Substantiated INVESTIGATIONS REVEALED: Based on records review, Resident #1 (R1) was admitted to the facility on 12/4/2022 and left the facility on April 4, 2023. R1 is non-ambulatory and has a mild cognitive impairment. R1 has a special diet of low sodium and low sugar. Regarding allegation: Staff did not follow safe food handling practices. It was reported that cooked and uncooked food are constantly exposed. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), and all five residents (R1-R5) denied that staff did not follow safe food handling practices. During LPA’s complaint visit on 5/3/2023 at 10:06 am until 10:16 am, LPA checked and observed several bags of bread and bags of chips were open and unsealed. LPA observed a bowl of meat, a glass container of gelatin and a soy sauce with sliced onions in the refrigerator uncovered. LPA also observed uncovered bowl of rice soup, chips and salsa near the stove oven. Based on gathered information and photos taken, there is sufficient evidence to prove that staff did not follow safe food handling practices. Regarding allegation: Staff did not keep resident's information confidential. It was reported that staff shared Residents’ confidential/medical information to visitors and residents’ confidential records are exposed and not locked. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), and all five residents (R1-R5) and a witness (W1) denied that staff did not keep resident’s information confidential. During the complaint visit on 5/3/2023 at 9:52 am, LPA observed residents’ confidential files including R1’s file were not locked and accessible. LPA advised S2 to keep and lock all confidential files. At 10:38 am, LPA observed R1’s confidential file folder was still accessible and not moved to a locked storage. Based on gathered information and photos taken, there is sufficient evidence to prove that staff did not keep resident’s information confidential. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 1,6), the following deficiencies had been observed and citations issued (ref. LIC 9099D). CIVIL PENALTY ASSESSED. An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator Virginia Asis.the state’s words, verbatim · CDSS document, May 4, 2023 · control 11-AS-20230428111619

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c) · Plan of correction due date: May 12, 2023

87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. During the complaint visit on 5/3/2023 at 9:52 am, LPA observed residents’ confidential files including R1’s file were not locked and accessible. LPA advised S2 to keep and lock all confidential files. At 10:38 am, LPA observed R1’s confidential file folder was still accessible and not moved to a locked storage. This poses a potential health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2023

Plan of correction: Administrator locked all residents' confidential information. Administrator shall give an in-service training to staff on Section 87506 of Title 22. POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date. CIVIL PENALTY ASSESSED FOR REPEAT VIOLATION (SEE 4/21/2023 for prior citation)

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8755(b)(9) · Plan of correction due date: May 12, 2023

87555 General Food Service Requireme (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. During LPA’s complaint visit on 5/3/2023 at 10:06 am, LPA checked and observed several bags of bread and chips were open and not sealed. LPA observed a bowl of meat, a glass container of gelatin and a soy sauce with sliced onions in the refrigerator uncovered. LPA also observed uncovered bowl of rice soup, chips and salsa near the stove oven. This poses a potential health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2023

Plan of correction: S2 covered all food and snacks during the visit. Administrator shall give an in-service training to staff on Section 87555 of Title 22. POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Allegation investigated: Staff physically assaulted resident while in care. Facility has pests. Staff did not meet resident's dental hygiene needs. Staff did not provide residents healthy nutritious meals. Staff did not follow resident's doctor's orders. Staff did not ensure that resident was adequately dressed. Staff mentally abused resident. Staff made inappropriate comments in front of resident. Staff did not adequately supervise residents. Resident sustained multiples injuries while in care.

***************This was amended in error. No changes were made. On 5/4/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced subsequent complaint visit at this facility to obtain additional information and to deliver complaint findings. LPA was greeted by Caregiver Allen Gloriani and House Manager/Caregiver Lucy Dezell. Administrator Virginia Asis arrived later and joined the visit. LPA explained the purpose of the visit. The investigation consists of the following: On 5/3/2023, LPA obtained copies of the facility roster for residents and staff. Interviews were conducted with three staff (S1-S3) and four residents (R2-R5). LPA was unable to obtain information from two residents (R6-R7) due R6’s medical condition and R7 is in the hospital. LPA obtained and reviewed R1's service records. A tour of the facility was conducted. On 5/4/2023, LPA interviewed one resident (R1) and one witness (W1) by telephone. However, LPA Montoya was unsuccessful in attempt to conduct telephone interview with one potential witnesss (W2). Report continued in LIC 9099C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Based on records review, Resident #1 (R1) was admitted to the facility on 12/4/2022 and left the facility on April 4, 2023. R1 is non-ambulatory and has a mild cognitive impairment. R1 has a special diet of low sodium and low sugar. Regarding allegation: Staff physically assaulted resident while in care. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), all five residents (R1-R5) denied staff physically assaulted resident while in care. S1 stated there are no reported incidents that staff physical assaulted residents while in care. W1 stated W1 heard that it was alleged that R1 was physically assaulted but W1 did not witness the incident and does not have any proof for the allegation. LPA did not observe any signs of physical assault to any residents in care during investigation visits. . Based on gathered information, there is no sufficient evidence to prove that staff physically assaulted resident while in care. Regarding allegation: Facility has pests. It was reported that rats are coming out of the wood planks in the back patio. LPA Montoya conducted interviews with three staff (S1-S3), all five residents (R1-R5) and a witness (W1). Based on interviews conducted, all three staff (S1-S3), and all five residents (R1-R5) denied that facility has pests. S2 and R2 stated sometimes squirrels appear on the retaining wall of the facility but they have not observed any rats inside and outside the facility. W1 stated W1 has not witnessed that facility has pests as W1 has not been to the facility. LPA did not observe any pests in the facility during the complaint visits. Based on gathered information, there is no sufficient evidence to prove that facility has pests. Regarding allegation: Staff did not meet resident's dental hygiene needs. It was reported that staff failed to brush R1’s teeth for weeks. LPA Montoya conducted interviews with three staff (S1-S3), all five residents (R1-R5) and a witness (W1). Based on interviews conducted, all three staff (S1-S3), and all five residents (R1-R5) denied that staff did not meet resident's dental hygiene needs. W1 stated W1 cannot provide comment to this allegation because W1 did not check on R1’s teeth. LPA was not able to observe R1’s teeth because R1 was no longer residing at the facility during the investigation visits. Based on gathered information, there is no sufficient evidence to prove staff did not meet resident's dental hygiene needs. REPORT CONTINUED IN LIC 9099C Regarding allegation: Staff did not provide residents healthy nutritious meals. It was reported that staff serves poor quality of food and not nutritious meals like KFC chicken, 711 pizza, candy, and cups of noodles. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3) and all five residents (R1-R5) denied that staff did not provide residents healthy nutritious meals. S2 stated staff serve three hot meals per day. S2 stated staff serve a balanced diet which includes a combination of protein, vegetables, fruits, rice or potato, soup, salad or sandwiches. W1 stated W1 has not heard or observed that staff did not provide residents healthy nutritious meals. LPA observed a menu with a balanced diet and LPA observed during the complaint visit on 5/3/2023 that staff served stewed pork, rice, stir fried vegetable, salad and fruits. Based on gathered information, there is no sufficient evidence to prove that staff did not provide residents healthy nutritious meals. Regarding allegation: Staff did not follow resident's doctor's orders. During pre-investigation, Reporting Party (RP) was unable to explain the allegation that staff did not follow doctor’s orders. RP stated there is no known doctor’s order for R1 that RP can remember. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3) and all five residents (R1-R5) denied that staff did not follow resident's doctor's orders. R1-R5 stated they don’t have doctor’s orders that staff need to follow. W1 stated W1 is unsure if R1 has doctor’s order that staff failed to follow. S2 stated staff follow residents’ special diet based on their medical conditions. S2 stated some residents require low sugar and/or low salt. Based on LPA’s records review, R1’s medical assessment dated 12/27/2023 shows R1 has a special diet. Based on gathered information, there is no sufficient evidence to prove that staff did not follow resident's doctor's orders. Regarding allegation: Staff did not ensure that resident was adequately dressed. It was reported staff sent R1 to the hospital naked and a former resident was allowed walking around the facility naked. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), all five residents (R1-R5) and a witness (W1) denied that staff did not ensure that resident was adequately dressed. R1 denied that staff sent R1 to the hospital without clothes on. W1 stated R1 was properly dressed when R1 visited the doctor’s clinic on 4/6/2023. LPA observed during the complaint visits that all residents are properly dressed. Based on gathered information, there is no sufficient evidence to prove that staff did not ensure that resident was adequately dressed. REPORT CONTINUED IN LIC 9099C Regarding allegation: Staff mentally abused resident. It was reported that staff mentally abused resident. PA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), all five residents (R1-R5) and a witness (W1) denied that staff mentally abused resident. S1 stated there is no reported incident that staff mentally abused resident. LPA did not observe any staff mentally abusing resident during the investigation visits. Based on gathered information, there is no sufficient evidence to prove that staff mentally abused resident. Regarding allegation: Staff made inappropriate comments in front of resident. It was reported that staff (S2) yelled and told administrator that S2 does not want to take care of R1 and R1 heard S2’s statement. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), all five residents (R1-R5) and a witness (W1) denied that staff made inappropriate comments in front of resident. LPA did not observe any staff making inappropriate comments in front of resident during the investigation visits. Based on gathered information, there is no sufficient evidence to prove that staff made inappropriate comments in the front of resident. Regarding allegation: Staff did not adequately supervise residents. It was reported that large pieces of apples were logged in resident’s mouth and staff allowing resident to walk around the facility butt naked and making sexual gesture to staff. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), and all five residents (R1-R5) denied that staff did not adequately supervise residents. W1 stated W1 did not witness this alleged incident. LPA reviewed a photo of R1 showing R1's mouth was open and a small piece of food was on R1's mouth but it is unclear when and where this incident happened. Based on gathered information, there is no sufficient evidence to prove that staff did not adequately supervise residents. REPORT CONTINUED IN LIC 9099C This page is amended to add the allegation below. Regarding allegation: Resident sustained multiples injuries while in care. It was reported that R1 had multiple large bruises, swelling on right arm, leg, and left foot while in care at this facility. The incident was reported to Torrance Police Department. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), all five residents (R1-R5) denied that resident sustained multiples injuries while in care. W1 stated according to doctor’s notes dated 4/6/2023, it was noted that R1 had a bruise on right arm and R1 complained of pain on left foot, left knee and left elbow. W1 stated R1’s doctor indicates the bruises and pain are not serious injuries and the cause is unknown. LPA was not able to obtain information from the Torrance Police Department about R1’s injury. Based on gathered information, there is no sufficient evidence to prove that staff made inappropriate comments in the front of resident. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegations are Unsubstantiated. An exit interview was conducted with Administrator Virginia Asis and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 4, 2023 · control 11-AS-20230428111619

Type of visit: Case Management - Deficiencies

On 5/3/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit at this facility. During an unrelated complaint visit, LPA observed the following deficiencies: Around 10:02 am, LPA observed two pairs of scissors and a knife on a dish drying rack in the kitchen and the drawer for sharp items was kept open and accessible. LPA observed a shovel in the backyard next to a storage shed; Around 10:20 am, LPA observed a cabinet (under the sink) for storing cleaning supplies (Cloralen, raid, fabulous, etc ) was open and accessible. Around 10:25 am, LPA observed a trowel and a large black rake in the backyard next to the sliding door. Around 11:45 am, LPA observed lysol, laundry soap and fabric softener in the laundry room were accessible. At around 10:23 am, LPA Montoya observed the right side gate is locked with a padlock. There is no sufficient lighting in bedrooms #2 and #3. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. CIVIL PENALTY ASSESSED. Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator Virginia Asis.the state’s words, verbatim · CDSS document, May 3, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1)(2) · Plan of correction due date: May 4, 2023

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This was not met as evidenced by: Based on record review, observation and interviews, the licensee failed to ensure items that could constitute a danger to residents with dementia are inaccessible. Around 10:02 am, LPA observed two pairs of scissors and a knife on a dish drying rack in the kitchen and the drawer for sharp items was kept open and accessible. LPA observed a shovel in the backyard next to a storage shed; Around 10:20 am, LPA observed the cabinet for storing cleaning suppplies (Cloralen, etc ) was open and accessible. Around 10:25 am, LPA observed a trowel and a large black rake in the backyard next to the sliding door. Around 11:45 am, LPA observed lysol, laundry soap and fabric softener in the laundry room were accessible. This poses an immediate health, safety and/or personal rights risk to residents in care with dementia.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Staff (#2) moved the sharp and toxic items in a locked storage inaccessible to resident with dementia. Administrator shall read Section 87705 and shall self-certify understanding of the regulations and shall conduct an in-service training to all staff. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date. CIVIL PENALTY ASSESSED.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(6) · Plan of correction due date: May 12, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This was not met as evidenced by: At around 10:23 am, LPA Montoya observed the right side gate is locked with a padlock. This poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Administrator removed the padlock and will ensure the side gate is always unlocked. Administrator shall read Section 87468.1and shall self-certify understanding of the regulations and shall conduct an in-service training to all staff. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a) · Plan of correction due date: May 12, 2023

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. Based on observation and interview, there is no sufficient lighting in bedrooms #2 and #3.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Administrator shall provide more lightings for room #2 and room #3. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Allegation investigated: Facility not serving residents an adequate amount of food. Facility is not serving nutritious meals to residents. Facility not following physician's orders. Facility is verbally abusive towards residents. Facility is not providing assistance to resident in care. Facility is not providing basic essentials to residents.

On 04/14/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced subsequent complaint visit at this facility to obtain additional information and to deliver complaint findings. LPA was greeted by Staff Tamico Thomas. Administrator Virginia Asis arrived later and joined the visit. LPA explained the purpose of the visit. The investigation consists of the following: On 4/11/2023, LPA Montoya interviewed three staff (S1-S3) and four residents (R1-R4). LPA was unable to complete a proper interview with R1. LPA reviewed all residents’ (R1-R5) physician’s reports and staff’s timesheets. A tour of the facility was conducted. On 4/13/2023, LPA interviewed one resident (R5) and reviewed all residents’ (R1-R5) admission agreements. Report continued in LIC 9099C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Regarding allegation: Facility not serving residents an adequate amount of food. It was reported that food portions served are not adequate and residents are left wanting more food. LPA interviewed three staff (S1-S3) and five residents (R1-R5). LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. R2 stated facility serves only one hot meal a day. Three staff (S1-S3) and two residents (R3-R4) revealed facility serves adequate amount of food to residents. R5 stated sometimes food portion served is more than enough, just enough or too little but additional food is available if requested. S2 mentioned that residents always appreciate staff for serving them with plenty of food on their plate. Based on gathered information, there is no sufficient evidence to prove that facility is not serving residents an adequate amount of food. Regarding allegation: Facility is not serving nutritious meals to residents. It was reported that residents are frequently given Bologna and noodles which are high in sodium and bad for those who have high blood pressure. LPA interviewed three staff (S1-S3) and five residents (R1-R5). LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. R2 answered “So-so” when LPA asked whether the facility is serving nutritious meals to residents. Three staff (S1-S3) and three residents (R3-R5) revealed facility is serving nutritious meals to residents in care. S2 stated S2 prepares a balanced diet with vegetables, protein, carbs and fruits for residents. R5 revealed facility staff serve nutritious meals which include protein, rice, vegetables, fruits with nuts, and juices. Based on gathered information, there is no sufficient evidence to prove that facility is not serving nutritious meals to residents. Regarding allegation: Facility is not following physician's orders. It was reported that caregiver does not stick to the care plan of doctor's orders. LPA interviewed three staff (S1-S3) and five residents (R1-R5). Staff (S1-S3) denied that facility is not following physician’s order. LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. When LPA asked residents if facility is not following physician’s order, R2 answered “It’s okay”, R3 said “I don’t have a doctor.”, R4 stated S2 serves R4 low sugar or sugar free diet as prescribed by the physician. Based on gathered information, there is no sufficient evidence to prove that facility is not following physician’s orders. REPORT CONTINUED IN LIC 9099C Regarding allegation: Facility staff is verbally abusive towards residents. It was reported that caregiver is verbally abusive to the residents. For some residents who do not have people visiting them, they are treated without regard. LPA interviewed three staff (S1-S3) and five residents (R1-R5). LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. Three staff (S1-S3) and four residents (R2-R5) denied that facility staff is verbally abusive towards residents. Based on gathered information, there is no sufficient evidence to prove that facility staff is abusive towards residents. Regarding allegation: Facility is not providing assistance to resident in care. It was reported that when one resident asked caregiver for water, the caregiver brought water to resident, but caregiver drank it in front of the resident and walked away. The Resident is not independent and cannot hold a cup independently. Same resident was left on the floor. LPA interviewed three staff (S1-S3) and five residents (R1-R5). LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. Three staff (S1-S3) and four residents (R2-R5) denied that facility is not providing assistance to residents in care. R4 revealed S2 is good at assisting residents in care. R5 stated due to motor impairment, facility staff assist R5 in moving in and out of the wheelchair. R5 revealed staff always provide assistance to residents. Based on gathered information, there is no sufficient evidence to prove that facility is not providing assistance to residents in care. Regarding allegation: Facility is not providing basic essentials to residents. It was reported that facility staff are constantly asking residents’ families to provide basic essentials, such as bottled water, food and cleaning supplies. LPA interviewed three staff (S1-S3) and five residents (R1-R5). LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. Three staff (S1-S3) and four residents (R2-R5) denied that facility is not providing assistance to residents in care. Three residents (R3-R5) revealed they buy their own hygiene supplies, but the facility has available basic essentials for residents. Based on gathered information, there is no sufficient evidence to prove that facility is not providing basic essentials to residents. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegations are Unsubstantiated. An exit interview was conducted with Administrator Virginia Asis and a copy of the report was provided. Regarding allegation: Facility is unsanitary. It was reported that the home looked unsanitary and did not appear clean. LPA interviewed three staff (S1-S3) and five residents (R1-R5). Three staff (S1-S3) and four residents (R2-R5) denied the facility is unsanitary. LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, kitchen floor is dirty, the bottom of the dishwasher had molded water and smelled malodorous, the laundry floor was covered with water leak, the ground of the right side of the facility is covered with molded water and white powder across the walkway. Based on gathered information, there is sufficient evidence to prove that facility is unsanitary. Regarding allegation: Facility is serving expired food to residents. It was reported that loaves of bread on the dining table have been there for months are served to residents in care. LPA interviewed three staff (S1-S3) and five residents (R1-R5). Three staff (S1-S3) and four residents (R2-R5) denied the facility is serving expired food to residents. LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. S2 revealed sometimes S2 checks the expiration of the food but sometimes S2 does not check the expiration because S2 has been busy working alone. Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, facility has expired food to residents. LPA observed the following expired food: Chicken Bolgna – expired on 2/7/2023; a bag of wheat bread – expired on March 1, 2023; a bag of white bread – expired on March 18, 2023; a bag of garden salad – expired on April 7, 2023, and lettuce looks saggy. Based on gathered information, there is sufficient evidence to prove that facility is serving expired food to residents. Regarding allegation: Facility is not properly cleaning dishes. It was reported that dishes are usually stacked high and not washed properly. LPA interviewed three staff (S1-S3) and five residents (R1-R5). Three staff (S1-S3) and three residents (R2, R3 and R5) denied the facility is not properly cleaning dishes. LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. R4 stated sometimes plates, cups and utensils are left overnight in the sink unwashed. LPA observed about five white plates stored in the cabinet are still wet and one of them has food residue on the edges of the plate. Based on gathered information, there is sufficient evidence to prove that facility is not properly cleaning the dishes. Regarding allegation: Lack of staffing. It was reported that there is only one caregiver for five (5) residents in the home. LPA interviewed three staff (S1-S3) and five residents (R1-R5) of which 3 residents are diagnosed with dementia. Three staff (S1-S3) and one resident (R4) denied there is lack of staffing in the facility. During interviews, LPA was unable to obtain clear response from one resident (R1) due to declining medical condition; R2 did not provide answer to this interview question; R3 and R5 observed only one staff (S2) is present in the facility every day, only on some days that another staff comes to help S2. Based LPA's review of staff time sheets, since January 2023 to April 2023, there were days that facility had only one staff on duty. Based on gathered information, there is sufficient evidence to that there is lack of staffing in the facility. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 1,6), the following deficiency had been observed and a citation issued (ref. LIC 9099D). An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator Virginia Asis.the state’s words, verbatim · CDSS document, Apr 14, 2023 · control 11-AS-20230403091737

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Apr 21, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This was not met as evidenced by: Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, kitchen floor is dirty, the bottom of the dishwasher had molded water and smelled malodorous, the laundry floor was covered with water leak, the ground of the right side of the facility is covered with molded water and white powder across the walkway. This poses a potential health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2023

Plan of correction: Administrator shall clean all the mentioned spaces in the home that are unsanitary. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Apr 21, 2023

87555 General Food Service Requirements (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This was not met as evidenced by: Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, facility has expired food. LPA observed the following expired food: Chicken Bolgna – expired on 2/7/2023; a bag of wheat bread – expired on March 1, 2023; a bag of white bread – expired on March 18, 2023; a bag of garden salad – expired on April 7, 2023, and lettuce looks saggy. This poses a potential health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2023

Plan of correction: Administrator shall discard all expired food and shall ensure the facility does not serve expired food to residents. Administrator shall read Section 87555 and shall provide an in-service training to all staff. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(30)(31)(B) · Plan of correction due date: Apr 21, 2023

87555 General Food Service Requirements (b) The following food service requirements shall apply:(30) All utensils used for eating and drinking and in preparation of food and drink, shall be cleaned and sanitized after each usage. (31) Dishes and utensils shall be disinfected: (B) In facilities not using mechanical means, by an alternative comparable method approved by the licensing agency or by the local health department, such as the addition of a sanitation agent to the final rinse water. LPA observed about five white plates stored in the cabinet are still wet and one of them has food residue on the edges of the plate. LPA observed the dishwasher is not in good repair. R4 stated sometimes plates, cups and utensils are left overnight in the sink unwashed. This poses a potential health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2023

Plan of correction: Administrator shall ensure all utensil for eating and drinking are always cleans and sanitizes. Administrator shall give staff an in-service training about this section. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(a)(1) · Plan of correction due date: Apr 21, 2023

87413 Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This was not met as evidenced by: Based on LPA’ review of staff’s timesheets and interviews conducted, there is a lack of staffing in the facility. Since January 2023 to April 2023, there were days that facility had only one staff duringd day and night. There are currently five residents in the home of which three are diagnosed with dementia. One out three residents with dementia is ambulatory, two are non-ambulatory. R3 and R5 observed only one staff (S2) is present in the facility every day and some days, another staff comes to help S2. This poses a potential health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2023

Plan of correction: Administrator shall ensure the facility has sufficient staffing all the time. Administrator shall submit an updated LIC 500 CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Type of visit: Case Management - Deficiencies

On 4/14/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit at this facility. During an unrelated complaint visit, LPA observed the following deficiency. During LPA's visit on 4/11/2023 AND 4/14/2023, LPA observed all five residents' records (folders) are stored in an unlocked cabinet. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator Virginia Asis.the state’s words, verbatim · CDSS document, Apr 14, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c) · Plan of correction due date: Apr 21, 2023

87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. During LPA's visit on 4/11/2023 AND 4/14/2023, LPA observed all five residents' records (folders) are stored in an unlocked cabinet. This poses a potential personal rights, health or safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 14, 2023

Plan of correction: Administrator shall ensure all residents records are kept confidential in a locked storage. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Type of visit: Case Management - Deficiencies

On 4/11/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit at this facility. During an unrelated complaint visit, LPA observed the following deficiencies. A staff (S1) who is not fingerprinted was observed working in the facility. S1 admitted to LPA that he started working as a caregiver at this facility on 4/4/2023. S1 disclosed that he worked on 4/4/23, 4/5/2023, 4/6/2023 and 4/11/2023. LPA observed the facility is in disrepair (see LIC 809D for details). LPA observed one resident (R1) who has dementia sitting at the back patio and a couple of shovels and a rake are leaning against the wall next to the patio. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Civil penalties assessed. Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator Virginia Asis.the state’s words, verbatim · CDSS document, Apr 11, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Apr 12, 2023

(e) All 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 was not met as evidenced by: Based on record review, observation and interviews, the licensee failed to ensure S1 is fingerprint clear prior to working. S1 started working as a caregiver in this facility on 4/4/2023. This poses an immediate health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 11, 2023

Plan of correction: Administrator shall read Section 87355(e)(1) and shall self-certify understanding of the regulations and shall commit to comply. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC87705(f)(1) · Plan of correction due date: Apr 12, 2023

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This was not met as evidenced by: Based on record review, observation and interviews, the licensee failed to ensure items that could constitute a danger to residents with dementia are stored inaccessible. LPA observed R1 who has dementia sitting at the back patio and a couple of shovels and a rake are accessible at the patio. LPA observed the cabinet under the sink where cleaning supplies such as bleaches, glass cleaner, etc. are stored is unlocked and accessible to residents with dementia.the state’s words, verbatim · CDSS document, Apr 11, 2023

Plan of correction: Administrator shall read Section 87705(f)(1) and shall self-certify understanding of the regulations and shall conduct an in-service training to all staff. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 14, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidenced by: Based on observations and interviews, the facility is in disrepair. The diswasher is broken and has malodorous smell, the back door is rotted, the floor in the laundry room is covered with water due to a leak, the outdoor patio is covered with dried leaves, the lock of the right side gate is not working properly and the kitchen floor and oven are dirty.the state’s words, verbatim · CDSS document, Apr 11, 2023

Plan of correction: Administrator shall ensure that the facility is always clean, safe, sanitary and in good repair. Administrator shall submit a POC for all the mentioned deficiencies to CCL via email to lourdes.montoya@dss.ca.gov by the POC due date.

Type of visit: Case Management - Annual Continuation

On 09/27/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a continuation of an annual inspection. LPA Montoya called the Administrator Virginia Asis (S1) who confirmed the facility is free of Covid-19 infection. LPA met with House Manager Lucy Dezell (S2) and Volunteer caregiver Patricia Ozekie (S3). LPA explained the purpose of the visit. Administrator Asis arrived later and joined the visit. There were three (3) residents present in the facility during the inspection. Technical violations and technical assistance were issued to licensee. The following deficiencies were observed on 9/23/22 (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. Appeal rights and a copy of this report was provided to Administrator Virginia Asis.the state’s words, verbatim · CDSS document, Sep 27, 2022

Type of visit: Required - 1 Year

On 09/23/2022 at 12:25 pm, Licensing Program Analysts (LPAs) Lourdes Montoya and Wendy Gibbs conducted an unannounced Required – 1 Year Inspection. LPA Montoya called the Administrator Virginia Asis (S1) who confirmed the facility is free of Covid-19 infection. LPAs met with House Manager Lucy Dezell (S2) and Volunteer caregiver Patricia Ozekie (S3). LPA explained the purpose of the visit. Administrator Asis arrived later and joined the visit. There were four (4) residents present in the facility during the inspection. Caregiver Rey Malit (S4) arrived to relieve Volunteer Ozekie. At around 1:44 pm, the Administrator and Staff 1 left the facility. Facility is licensed licensed to serve clients age 60 and over, six (6) non-ambulatory. Approved Hospice Waiver for six (6) residents. The Annual Licensing Fees are current. The facility is a single story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms, 2 bathrooms, living room, kitchen, dining room, family room, garage and a shaded area. LPA Montoya toured and inside and outside grounds of the facility with Staff Dezell. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was 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 measured at 124.4 and 124.0 degree Fahrenheit in resident bathrooms. A comfortable temperature was maintained in the facility. LPA observed the facility was found to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility has (1) fire extinguisher that was charged, smoke detectors, and carbon monoxide were operable. One fire extinguisher located in the laundry room mounted on the wall was last serviced on 2/15/2018. The facility conducted a Fire/Safety Drill on 7/26/2022. A working telephone 424-558-8285 remains available. Evaluation Report Continues on LIC 809-C During the visit, LPA observed the facility's infection control practices. LPA observed a sanitizing station in common areas. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD. LPA Montoya and LPA Gibbs observed the following deficiencies. 1. Volunteer staff (S3) – No fingerprint /background clearance and not Associated to the facility. 2. Water temperature in the common bathroom is 124.4 degree Fahrenheit and the water temperature in bedroom # 3 is 124.00 degree Fahrenheit. 3. Fireplace in the family room is not properly screened. 4. Yellow basin with water was observed in the backyard. 5. Three stove burners not operable. 6. Sliding door screen is torn; sliding door and screen door are not in good repair. 7. Doorbell is broken off the wall. 8. Administrator made false statements about volunteer staff’s (S3) start date of work and worked days. 9. PUB 475 is on 8”x12” paper. 10. No Covid-19 screening form; No screening records 11. No handwash poster in both bathrooms. 12. Plastic container of frozen fries is not properly sealed. 13. Medication is dispensed to another container one week prior to administration per Staff 2. 14. Resident #1 has no Physician’s Report on file. 15. Former residents’ wheelchairs are stored in the garage. 16. Expired food per Resident #2. 17. Auditory devices in the main door and sliding door in the kitchen are not operable. 18. A fire extinguisher in the laundry was last serviced on 2/15/2018. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the above deficiencies. Due to time constraints, the annual inspection will be continued at a later date and citations will be issued for the above deficiencies. Administrator and the House Manager were no longer present in the facility during the exit interview. An exit interview was conducted with Staff Rey Malit and a hard copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 23, 2022