NP Care Home

Type of visit: Required - 1 Year

On 10/06/23, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the Care Inspection Tool. LPA was first greeted by Caregiver Lakisha Whetstone then was joined with administrator Ronic Tatum and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be bedridden of elderly residents ages 60 and above. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident's rooms, two (2) common bathrooms, one (1) staff bathroom, living area, dining area, kitchen, outside covered patio area, and a laundry room. A garage is being used for storage and office space. LPA and administrator toured the physical plant. 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 109.3 in bathroom number one (1) and 114.3.8 F in bathroom number two (2). A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored, yet accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available, maintained properly. A fire extinguisher was charged, six (6) smoke detectors and carbon monoxide were operable. The facility has a working landline telephone and the last fire drill was conducted on September 2023. See LIC809-C During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff residents 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 with CCLD. No deficiencies were cited during this inspection visit. An exit interview was conducted and a copy of this report was provided to Ronic Tatum.the state’s words, verbatim · CDSS document, Oct 6, 2023

Allegation investigated: Resident sustained injuries from a fall while in care.

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Krystal Adams, Administrator The investigation consisted of following: Interviews and Record reviews.On 06/23/23, LPA Soto interviewed R#1 - R#6. LPA Soto obtained residents file (Care services, Daily plan, Needs and Service Plan, Physician Reports, Preplacement appraisal, ID/Emergency Information, Admission Agreement, Mars for December 2022, SIR, and work schedule for December 2022.) On 05/30/23, LPA Soto conducted interviews with the S#1 - Administrator and S#4 & via telephone - S#5. LPA Soto also requested copies of the following documents: Resident and Staff rosters. On 12/14/22, LPA Alvizar interviewed Administrator, Staff S#2 - S#3, R#1 - R#2. Unsubstantiated Received the following documents on 12/14/22: Copy of the resident complete facility file to include but not limited to Staff and Resident Roster, Needs and Service Plan for R#1, Physician Report for R#1, Medication list for R#1, SIR report R#1 and time sheets. LPA and Administrator toured the facility including 3 bathrooms, 4 bedrooms, dining room, living room and kitchen. Based on the LPA's investigation, the investigation revealed the following. Allegation – Resident sustained injuries from a fall while in care. Interviews with S#1, S#4, & S#5, they communicated that the resident's fall was un-witnessed. Resident was found by S#5 around 7am when their shift began. S#5 was checking in on the residents going to get them ready for the day. The resident was on the floor with residents head bleeding, but responsive. Resident was opening their eyes. S#5 communicated that S#5 asked resident what had happened and why did resident try to get out of bed on their own. Resident only looked at S#5 and stated that resident did not know what had happened. S#5 called Administrator and 911, the resident was taken to the E.R. Resident's bed had the half rails up and they are not sure how the resident got out of bed. The resident had never done that before, resident had always waited for assistance to get out of bed. Staff #3 that was working that night, did not hear, see or was aware that the resident had fallen. Staff member was taking care of another resident at the time of the incident. The last time staff #3 checked on resident was that morning around 6:40am to 6:45am and they were fine in their bed. Interviews with R#1, R#2, R#3, R#4, and R#6, communicated that they have never fallen or witnessed any other resident fall. R#5, communicated that they were the residents roommate, they shared the room. R#5, only heard the fall, but did not witness the fall. R#5, believes that there was no staff member in the room at the time of the fall. R#5, believes they were alone, but they are not too sure because the rails were up on their bed and the rails obstructed their view. LPA Soto reviewed resident physician's report dated 05/14/21, resident required assistance with all their ADL's and was diagnosed with Dementia. Resident could walk, but with assistance from the staff. LPA reviewed resident's Daily schedule, resident was given a bed alarm to be placed on resident bed rails to go off when resident moved out of bed. Resident's family provided the alarm. S#1 communicated that the alarm had broken about 6 months prior to the incident and they informed the family, so they could replace the alarm but family never replaced the alarm for their resident. Interviews and records review did not concur with the above allegation. 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. An exit interview was conducted with Krystal Adams, Administrator, and a hard copy of report was provided.the state’s words, verbatim · CDSS document, Jun 23, 2023 · control 11-AS-20221209162052

Type of visit: Case Management - Deficiencies

On 12/14/22, Licensing Program Analyst (LPA) Antonia Alvizar conducted a case management inspection visit at this facility. LPA was greeted by Caregiver, Milere Martinez then later Krystal Perkins, Administrator joined and explained the purpose of the visit. LPA was at this facility in conjunction with complaint # 11-AS-20221209162052. During the visit LPA was made aware the facility failed to adhere to regulations Title 22 Section 87355(e)(1). LPA identified and confirmed staff #1 (S1) worked at this facility from 01/02/22 to 12/14/22 caring for residents without proof of criminal clearance background approval. Krystal, Administrators stated, "S#1 will not return to work until obtained a California Clearance or a Criminal Record Exemption as required by (CCLD) Community Care Licensing Division. Based on the information gathered, the licensee violated the California Code Regulations (CCR) of Title 22 sections 87355(e)(1) Division 6 Chapter 8. Citation is issued, civil penalties assessed, and exit interview conducted a copy was provided to Administrator, Krystal Perkins.the state’s words, verbatim · CDSS document, Dec 14, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Dec 14, 2022

87355 Criminal Record Clearance: 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 Based on observation and interviews, the Administrator did not comply with the section cited above. The facility did not have approved criminal record clearance for S#1.This violation poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 14, 2022

Plan of correction: Administrator will adhere to title 22 and will ensure that all staff are criminal record clearance reviewed and approved. The administrator will remove all staff that are not criminal record clearance approval.

Type of visit: Required - 1 Year

On 12/02/22, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit with a primary focus on Infection Control measures and the purpose of today's visit has been explained. LPA met with administrator Ronic Tatum and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be bedridden of elderly residents ages 60 and above. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, outside covered patio area, and a laundry. A garage is being used for storage and office space. LPA and administrator toured the physical plant. 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 119.8 F in bathroom number two (2). A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored, yet accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available, maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. The facility has a working landline telephone and the last fire drill was conducted on 11/27/22. See LIC 809-C During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff residents 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. A review of staff Fit Testing is maintained and accurate. The facility has an approved Mitigation Plan Report with CCLD. There were two (2) deficiencies cited during this inspection visit, see LIC809-D. There were technical assistance notes provided, see LIC9102. An exit interview was conducted and a copy of this report was provided to Krystal Perkins.the state’s words, verbatim · CDSS document, Dec 2, 2022

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff do not follow COVID-19 protocol Staff do not assist resident with incontinence care Staff speak inappropriately to resident Facility does not meet resident's nutritional needs Staff did not seek medical care for resident Staff did not inform responsible party of resident's change in condition

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility on 07/25/2022 at around 09:00 AM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10 day visit on 03/01/2022 approximately around 09:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 03/01/2022 LPA Calderon interviewed W1 for complaint. On 03/01/2022 LPA Calderon requested copies of the following: Staff and Resident rosters, admission agreement, Needs and Service Plan, Physician Report, MAR, Kaiser hospital records for R1. On 07/25/2022 LPA Calderon reviewed medical records for R2-R4. On 07/25/2022 LPA Calderon attempted to interview R2-R6 for complaint. On 03/01/2022 LPA Calderon interviewed S2 – S3 for complaint. On 07/25/2022 LPA Calderon reviewed medical records for R1. Unsubstantiated Regarding Allegation #1: Staff do not follow COVID-19 protocol. On 03/01/2022 LPA Calderon interviewed W1 who states that staff did not wear masks and residents were not wearing mask. W1 states that staff did not follow covid-19 protocols and did not test guest coming into the facility. On 03/01/2022 LPA Calderon interviewed S1-S3 who all state that they wear mask every time they are inside the facility and test for covid-19 and take the temperature of any guest that come into the facility. Staff states that they follow all protocols regarding covid-19. On 03/01/2022 and 07/25/2022 LPA Calderon noted staff following covid-19 protocols while inside the facility. Regarding Allegation #2: Staff do not assist resident with incontinence care. On 03/01/2022 LPA Calderon interviewed W1 who states that staff were not taking care of R1 incontinence care and were not changing the resident while sleeping in the bed. On 03/01/2022 LPA Calderon interviewed S1-S3 who state that R1 is well cared for and R1 diaper is changed when needed. Staff states that R1 incontinence care is taken care of by staff or by the hospital. On 07/25/2022 LPA Calderon reviewed medical records for R1 to include needs and service, physician report and Kaiser hospital records. All records state no issues with incontinence care for R1. On 07/25/2022 LPA Calderon reviewed medical records for R2-R4, no issues noted for incontinence care by staff. On 09/19/2022 LPA Calderon interviewed S1 who states that R1 does have a incontinence care plan from R1 doctor which staff follows. S1 states that R1 diapers are changed 4 to 6 times per day depending on R1 needs and the number of times R1 goes to the bathroom. S1 states that facility staff is trained for incontinence care needs of all residents in their care. Regarding Allegation #3: Staff speak inappropriately to resident: On 03/01/2022 LPA Calderon interviewed W1 who states that staff yells at R1 and speaks to R1 inappropriately. On 03/01/2022 LPA Calderon interviewed S1-S3 who state no staff yells at residents and never speaks to residents inappropriately. On 07/25/2022 LPA Calderon reviewed records for R1-R4, there are no reports from residents or resident family of any staff speaking to residents in an inappropriate manor. On 03/01/2022 and 07/25/2022 LPA Calderon noted the interactions between staff and residents which there did not appear to be any issues. Regarding Allegation #4: Facility does not meet residents’ nutritional needs. On 03/01/2022 LPA Calderon interviewed W1 who state that R1 is not being fed food and staff are not following doctors’ instructions regarding feeding R1. On 03/01/2022 LPA Calderon interviewed S1-S3 who state that they follow all physician instructions regarding feeding R1 and all residents in the facility. Staff state that R1 is diabetic, but there are no doctors’ instructions regarding the feeding R1. On 07/25/2022 LPA Calderon reviewed resident R1-R4 files and medical records and there is no physician report as to what to feed R1 or R2-R4 in their records. Records do support that R1 is diabetic. On 03/01/2022 and 07/25/2022 LPA Calderon noted staff feeding residents for breakfast and lunch. Regarding Allegation #5: Staff did not seek medical care for resident. On 03/01/2022 LPA Calderon interviewed W1 who states that staff refused to take resident to the hospital when needed. On 03/01/2022 LPA Calderon interviewed S1-S3 who state that W1 and W1 family did not allow staff to call 911 or take R1 to the hospital. Staff states that they called R1 family and was advised by W1 not to call 911 or transport R1 to the hospital. Staff states they follow all DSS regulations and call 911 when needed and make sure that all residents medical needs are taken care of. On 07/25/2022 LPA Calderon reviewed R2-R4 medical files and there is no report regarding 911 calls or residents being taken to the hospital. R1 records do show R1 being taken to the hospital on 01/03/2022, but no other hospital records are found. Regarding Allegation #6: Staff did not inform responsible party of residents change in condition. On 03/01/2022 LPA Calderon interviewed W1 who states that staff did not call W1 or W1 family regarding any medical changes to R1 or R1 being taken to the hospital. On 03/01/2022 LPA Calderon interviewed S1-S3 who state that they did call W1 regarding any medical change to R1 and S1-S3 all state that W1 did not want facility staff to call 911 or take R1 to the hospital. Staff states that they always call resident’s family informed or any medical change to R1. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of Staff do not follow covid-19 protocol, staff do not assist resident with incontinence care, staff speak inappropriately to resident, facility does not meet residents nutritional needs, staff did not seek medical care for resident, staff did not inform responsible party of residents change in condition is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator (Krystal Adams).the state’s words, verbatim · CDSS document, Jul 25, 2022 · control 11-AS-20220228124158

Allegation investigated: Staff did not seek timely medical attention for resident who sustained a fracture to hip requiring surgery.

Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent visit to deliver complaint investigation findings. LPA met with Licensee Krystal Adams and explained the purpose of the visit. Investigation consisted of the following: During the initial visit conducted on 2/18/20, LPA Gonzalez requested a copy of Staff and Resident rosters, reviewed Resident 1-3 (R1-3) facility files, and collected copies of various documents from resident files. LPA Gonzalez and Licensee Krystal Adams conducted a tour of the entire facility inside and out which included a Health & Safety check and observation of residents. LPA did not observe any signs of neglect, abuse or other immediate Health & Safety concerns at the time of the visit. The investigation for this complaint was conducted by Investigator Lorraine Patterson. (See LIC 9099C for continuation of report) Substantiated During the course of this investigation, Investigator Patterson conducted interviews with R1's FM and Licensee Krystal Adams. The investigation revealed the following: Regarding allegation of Staff did not seek timely medical attention for resident who sustained a fracture to hip requiring surgery. Investigator Patterson interviewed R1's FM who stated that on 1/15/20 they received a call from the facility licensee/ administrator, Krystal Adams, who reported to them that R1 had sustained an unwitnessed fall on 1/14/20 that went unreported by S1-2. R1's FM reported to Investigator Patterson that they were also informed that S1-2 assisted R1 back into bed after the unwitnessed fall. R1's FM stated that R1 did not receive timely medical care after the fall and was not assessed until 1/16/20 at which time GL Hospice came to the facility to take a portable x-ray of R1. X-Rays showed that R1 sustained a hip fracture and required surgery. R1 was taken off of hospice care on 1/17/20 due to the need for surgery and was transported via private ambulance, which was paid by the facility, to UCLA Santa Monica and had hip surgery on 1/18/20. R1 did not return to the facility after their discharge from the hospital and was placed in a Skilled Nursing Facility. Investigator Patterson also interviewed Licensee/ Administrator Krystal Adams, who confirmed that R1 fell on 1/14/20 and that S1 and S2 both failed to report the fall to licensee/ administrator. Licensee Adams stated that she found out about the fall/ injury until nearly 24 hours after the incident when another facility staff (S3) called her to notify her and asked her to come to the facility to assess R1. Mrs. Adams stated that she arrived at the facility late in day on 1/15/20 and she assessed R1 and being a medical professional (Nurse Practitioner) she noticed immediately that one of R1's legs looked shorter than the other and required medical attention, at which time she contacted R1's family members and GL Hospice. Licensee also stated that R1 did not receive medical attention until 1/16/20 when a Registered Nurse from GL Hospice visited R1 and took X-Rays which confirmed that R1 sustained a hip fracture and required surgery. Licensee stated that she informed R1's family about R1's need for surgery at which time the family struggled to decide on whether to call 911 or to use private transportation due to hospital preferences. Licensee stated that R1 was transported to UCLA Santa Monica via private ambulance paid for by the facility. R1 was admitted to the hospital on 1/17/20 and had hip surgery on 1/18/20. Licensee stated that R1 did not return to the facility. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. Immediate Civil Penalties will be issued today, in the amount of $500.00 due to Staff did not seek timely medical attention for resident who sustained a fracture to hip requiring surgery. At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1548(f)(1)(B)(i) and may be assessed at a later date. Exit interview held. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421M (Civil Penalty Assessment), and Appeal Rights were provided to Licensee Krystal Adams.the state’s words, verbatim · CDSS document, Nov 9, 2021 · control 28-AS-20200213103247

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Nov 10, 2021

Additional Personal Rights of Residents in Privately Operated Facilities To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: R1 sustained a hip fracture on 1/14/20 that subsequently required surgery and facility staff did not report injuries to facility administrator/licensee until nearly 24 hours later. This poses an immediate hazard to residents in care.the state’s words, verbatim · CDSS document, Nov 9, 2021

Plan of correction: Licensee is to retrain staff in residents needs and staff responsibilities and provide copy of training to LPA by Plan of Correction (POC) date. **Immediate Civil Penalties will be assessed in the amount of $500.00.**

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Nov 10, 2021

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: R1 sustained a hip fracture on 1/14/20 that subsequently required surgery and facility staff did not report injuries to facility administrator/ licensee until nearly 24 hours later. This poses an immediate hazard to residents in care.the state’s words, verbatim · CDSS document, Nov 9, 2021

Plan of correction: Licensee shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87464(d). Written POC must be submitted to CCL by the POC due date.

Type of visit: Required - 1 Year

On 10/19/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Krystal Adams and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be bedridden of elderly residents ages 60 and above. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, outside covered patio area, and a laundry. A garage is being used for storage. LPA and administrator toured the physical plant. 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 105.0 F. A comfortable temperature of 72 degrees was maintained in the facility. LPA observed the facility to be sanitary and 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 available maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. The facility has a working landline telephone. A Fire Drill was conducted on 10/05/21. Evaluation Report Continues on LIC 809-C During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff residents 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. A review of staff Fit Testing is maintained and accurate. The facility has an approved Mitigation Plan Report with CCLD. No deficiencies were cited during this inspection visit. An exit interview was conducted and a copy of this report was provided to Krystal Adams by email.the state’s words, verbatim · CDSS document, Oct 19, 2021