Magnificent Manor

Allegation investigated: Staff do not ensure that the facility is free from pests. Staff do not ensure that residents is provided with activities. Staff do not ensure that residents is provided with an appropriate variety of foods. Staff are isolating residents.

On 10/11/23, Licensing Program Analyst (LPA), Wendy Gibbs, initiated an complaint investigation at the faciltiy listed above. During today's visit LPA met with Administrator, Minda Mcnamara, and explained the purpose of today's visit. During today's visit LPA toured the facility, interviewed staff (S1-S4) and residents (R1-R6) and received documents pertinent to the investigation. Documents received and rewiewed were Staff Roster, Resident Roster, Menu, Resident Admission Agreement, Physician Report, Pre Apprisail, Needs and Service Plan, and receipts from exterminator company. Continued on LIC9099-C Unsubstantiated Allegation: Staff do not ensure that the facility is free from pests. The allegation alleges that there are flies and gnats flying around the facility and in the dining area. During todays visit LPA did not observe any insects in the facility. LPA observed two meals served at the facility and did not see any insects in the dining room or kitchen. LPA reviewed documents from the exterminator company that comes monthly. During interviews with staff (S1-S4) four out of four stated they have not seen any insects flying around the facility and the facility is treated monthly for any insects. During interviews with residents (R1-R6) five out of six stated they have not seen any insects in the facility, and one out of six stated they have seen a fly a few times in the facility. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff do not ensure that residents are provided with activities. The allegation alleges that residents mostly just sit in their rooms all day, every day because staff do not provide activities. LPA observed residents with a daily newspaper and other materials to read. LPA observed a karaoke book and set up, in the living room available for residents. LPA observed games, activities, and reading material available for residents located in the living room. During interviews with staff (S1-S4) four (4) out of four (4) stated they offer activities, exercise, and outside activities like a walk to residents and encourage them to participate. Three out of three Staff (S2, S3 and S4) stated there are a few residents who choose not to participate in activities. During interviews with Residents (R1-R6) six out of six stated there are activities offered by staff at the facility. Residents (R1, R3, and R5) three out of three stated they do not usually participate in activities because they don’t want to. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Continued on LIC9099-C Allegation: Staff do not ensure that resident is provided with an appropriate variety of foods. The allegation alleges that staff give resident the exact same thing to eat every day. During visit, LPA observed breakfast and lunch at the facility, residents had a variety of food to eat. LPA reviewed the sample menu and weekly menu posted and observed a variety of foods provided to residents. During interviews with staff (S1-S4) four out of four stated food is prepared before every meal, and everything they use is fresh. Staff stated they do not serve food left over from previous meals or the same foods every meal. Staff (S2, S3, and S4) stated they have a resident that they make food special for every day because the resident wants what they like. During interviews with residents (R1-R6) five out of six residents stated they get a variety of foods. One out of six residents stated they need soft food otherwise it upsets their stomach, and the staff makes them what they like to eat. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff are isolating resident. The allegation alleges that staff do not ensure all residents are taken to communal areas for socialization. LPA observed residents in the dining room visiting and drinking coffee or water. Additionally, LPA observed five residents during lunch eating together. LPA observed R1 in their room and when asked why they were not in the dining room with the others R1 responded because I wanted to stay here. During interviews with staff (S1-S4) four out of four stated residents are encouraged to join other residents during meals and activities. Staff (S2, S3, and S4) three out of three staff stated there are a few residents that tell them “Not today,” when asked if they want to go to the living room, dining room, or outside. During interviews with residents (R1-R6) six out of six stated they are not isolated and have not been isolated. Residents R1 and R3 stated they do not always want to go to the living room or dining room and prefer to stay in their room. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator, Minda Mcnamara, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 11-AS-20231006165632

Allegation investigated: Resident sustained pressure injury while in care. Unlawful eviction. Facility staff did not seek timely medical attention for resident. POA's request for copies of confidential paperwork declined. Resident care needs are not being met. Staff are not safeguarding resident's property.

On 3/02/2023 Licensing Program Analyst (LPA) Mario Leon and Licensing Program Manager (LPM) Ulysses Coronel initiated a subsequent complaint visit for the allegations listed above to deliver findings. Today’s complaint investigation was conducted with Pampee Mejia - Assistant Administrator. The investigation consisted of the following: On 02/10/2022 Licensing Program Analyst (LPA) Don Senaha interviewed residents (R2-R6) and staff (S1-S3). LPA requested service documents for residents s(R1-R6). Investigation revealed: Allegation: Resident sustained pressure injury while in care During interviews S1-S3 verified staff follow the care plans. S1 stated there has been no issues with pressure injuries to residents while in care. On 10/18/2021 S3 reported that R1 developed a wound. Witness (W3) was not able to provide interviews during this investigation. See LIC9099-C Unsubstantiated Record reviews and interviews conducted indicate that R1 was under a hospice care plan during the periods of 06/23/2021-10/19/2021 and 10/19/2021-01/10/2022. Hospice records indicates that R1 is at risk of skin breakdown due to existing health issues. Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Unlawful eviction During interviews R2-R6 stated there are no concerns with an unlawful eviction. S1-S3 stated there are no concerns with an unlawful eviction. Witness W3 was not able to provide interviews during this investigation. Record Reviews indicate that witness W3 discharged R1 from the hospital and did not return R1 to the facility. LPA did not observe any other incident reports regarding an eviction for the facility. Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Facility staff did not seek timely medical attention for resident. During interviews S1 and S2 verified that W3 called 911 on 01/11/2022. Witness W3 was not able to provide interviews during this investigation. Records indicate R1 was given treatment by S3 on 01/10/2022. Facility records indicate that S1, Administrator and hospice left voice messages for W3 about R1 condition after treatment was complete. Record reviews indicate witness (W3) refused to continue hospice services and called for paramedics on 01/11/2022. Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: POA’s request for copies of confidential paperwork declined. During interviews S1 stated no resident’s POA request for copies of confidential paperwork was declined. W3 did not verify the POA’s request for copies of confidential paperwork that was declined. See LIC9099-C Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Resident care needs are not being met. During interviews R2-R6 stated there are no concerns with resident care needs not being met. S1-S3 stated there are no concerns with resident hygiene, S2 stated that residents are bathed at least twice a week. Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff are not safeguarding resident’s property. During interviews R2-R6 stated there are no issues with staff are not safeguarding resident’s property. S1-S3 stated there are no issues with staff are not safeguarding resident’s property. LPA did not observe any other incident reports regarding staff are not safeguarding resident’s property. Based on the interviews conducted and records review, LPA was unable to find evidence to support the allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. On 03/02/2023, a copy of the report was printed and left with Pampee Mejia. End of Reportthe state’s words, verbatim · CDSS document, Mar 2, 2023 · control 11-AS-20220204131700

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Ursulyn Ubarra Caregiver the purpose of today’s visit was explained. There are currently (5) residents in the facility. (4) residents are ambulatory, (1) are non-ambulatory, (0) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (5) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and attached 2 garage. LPA and Ursulyn Ubarra Caregiver and later Minda Mc Namara Administrator toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-5 are occupied by residents and contain the mandated furniture. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is (118.9) degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (1) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE, mitigation plan posted and/or in folder, Fit testing not completed for staff, required postings are throughout the facility. Visitor designated area, facility has internet & IPAD for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All residents and staff are vaccinated and boosted. Technical Advisory (TA) issued for N95 fit testing. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time. An exit interview conducted with Minda Mc Namara Administrator a hard copy of report providedthe state’s words, verbatim · CDSS document, Jan 4, 2023

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 01/07/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Licensee Joseph Sol and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly non-ambulatory residents ages 60 and above. Facility is approved for four (4) bedridden and has a hospice wavier for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) bathrooms, living area, dining area, kitchen and outside covered patio area with a table and chairs. There is a detached garage with used for storage. The garage consists of the washer and dryer for laundry. LPA and Licensee 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 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 between 114.0 F and 120.0 F in the bathrooms and kitchen. 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 and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. One (1) fire extinguisher was fully charged next to the kitchen, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate. First aid kit available in the medicine cabinet area. Evaluation Report Continues on LIC 809-C During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed 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. Advisory Notes - Technical Assistance was issued, please see LIC9102-AN. No deficiencies were cited during the visit. An exit interview was conducted, and a copy of this report was provided to staff Garick Calpito which was ok with Licensee Joseph Sol who had to leave for another obligation.the state’s words, verbatim · CDSS document, Jan 7, 2022

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

Allegation investigated: Resident sustained pressure injuries while in care.

Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Complaint Visit to this facility and met with administrator Minda McNamara. The purpose of this visit is to deliver the findings of the investigation completed by Investigations Branch Supervising Investigator (IB) Donald Arvidson for the allegation listed above. The investigation consisted of the following: On 03/10/2021 IB conducted interviews with 2 staff, 4 residents and 2 witnesses. On 05/26/2020 IB interviewed administrator Rosendo Carlo Miranda. IB reviewed facility, staff and resident records, during the course if this investigation. The investigation revealed the following: Regarding the allegation: Resident sustained pressure injuries while in the care. The department received an allegation that resident #1 (R1) developed pressure injuries from October 2019 to February 2020. Home Health Records indicate that R1 was being treated by a wound care nurse during the months of January and February of 2020, on 12/31/2019 R1 was noted having wound Substantiated on the left buttocks increasing in size, on 01/12/2020 Physicians order indicate that R1 had unstageable pressure injuries on the left and right buttocks, on 01/20/2020 the wound on R1’s left and right buttock combined as a sacral wound and was unstageable. Home Health Records indicate that R1 had Unstageable and stage III pressure injuries. Hospital records indicate that, on 02/19/2020 R1 was sent to the hospital and was diagnosed with stage III and unstageable pressure injuries then was discharge to the facility and on 02/28/2020 R1 was sent back to the hospital where R1 was admitted. On 05/26/2020 IB interviewed the administrator Rosendo Carlo Miranda who stated that: towards the end of February 2020 R1’s home health nurse advised that “the wound was getting worse and R1 needed a higher level of care”. The administrator also stated that they recommended to R1’s family that “R1 needs to be transferred to a skilled nursing facility”. The administrator stated that “The wound may have been a stage III the last week of R1’s family was arranging the transfer." And after a week and a half the administrator decided to call an ambulance to transfer R1 to the hospital. IB observed that the administrator’s statements seem to coordinate with R1’s hospitalization on 02/19/2020 and 02/28/2020. Regarding the allegation: Resident developed a prohibited health condition while in care. Based on IB’s observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Civil Penalties were assessed on a similar allegation during investigation of another complaint with control number 11-AS-20200309132542. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, plans of corrections were discussed. A copy of this report and appeals rights were provided. On 03/10/2020 staff S1 stated that “R1 had a sore at their bottom and wore diapers and R1 would go pee in their diapers, so their wound area was constantly wet from pee.”, and stated “We changed R1’s diapers when needed and rotated them every 2 hours.” On 09/25/2020 Witness W4 stated that “On 01/21/2020 R1’s bed cover was wet with what smelled, like urine I would go different times after that, to try and see but I did not observe R1 being wet". Regarding the allegation: Staff left resident in soiled diaper. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. An exit interview conducted, a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2021 · control 11-AS-20200312105209

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Oct 8, 2021

Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on IB’s investigation the licensee failed to ensure that persons with stage 3 and 4 pressure injuries are not retained in a residential care facility for the elderly. R1 who had unstageable and stage 3 pressure injuries was retained at the facility which posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2021

Plan of correction: The licensee will conduct a training about Title 22 Regulation 87615(a)(1) Prohibited Health Conditions. Proof of correctiion will be submitted by POC due date. Civil Penalties were assessed on a similar allegation during investigation of another complaint with control number 11-AS-20200309132542.

Allegation investigated: Resident developed a prohibited health condition while in care

Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Complaint Visit to this facility and met with licensee Joseph Sol administrator Minda McNamara. The purpose of this visit is to deliver the findings on the investigation completed by Investigations Branch Supervising Investigator (IB) Donald Arvidson for the allegation listed above. The investigation consisted of the following: On 03/10/2020 IB conducted interviews with 2 staff, 4 residents and 2 witnesses. On 05/10/2020 IB interviewed witness #3 (W3). On 05/26/2020 IB interviewed administrator Rosendo Carlo Miranda. IB reviewed facility, staff and resident records, during the course if this investigation. The investigation revealed the following: Regarding the allegation: Resident developed a prohibited health condition while in care. The department received an allegation that resident #1 (R1) developed pressure injuries while in care. Substantiated Home Health Records indicate that R1 was being treated by a wound care nurse during the months of January and February of 2020, on 12/31/2019 R1 was noted having wound on the left buttocks increasing in size, on 01/12/2020 Physicians order indicate that R1 had unstageable pressure injuries on the left and right buttocks, on 01/20/2020 the wound on R1’s left and right buttock combined as a sacral wound and was unstageable. Home Health Records indicate that R1 had Unstageable and stage III pressure injuries. Hospital records indicate that, on 02/19/2020 R1 was sent to the hospital and was diagnosed having stage III and unstageable pressure injuries then was discharge back to the facility and on 02/28/2020 R1 was sent back to the hospital where R1 was admitted. On 05/26/2020 IB interviewed the administrator Rosendo Carlo Miranda who stated that: towards the end of February 2020 R1’s home health nurse advised that “the wound was getting worse and R1 needed a higher level of care”. The administrator also stated that they recommended to R1’s family that “R1 needs to be transferred to a skilled nursing facility”. The administrator stated that “the wound may have been a stage III the last week of R1’s family was arranging the transfer. And after a week and a half the administrator decided to call an ambulance to transfer R1 to the hospital. IB observed that the administrator’s statements seem to coordinate with R1’s hospitalizations on 02/19/2020 and 02/28/2020. Regarding the allegation: Resident developed a prohibited health condition while in care. Based on IBs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Civil Penalties assessed please see LIC421IM. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, plans of corrections were discussed. A copy of this report and appeals rights were provided. Record reviews indicate that on 07/13/2016 R2 was diagnosed with Vascular Dementia, on 08/23/2016 was placed on hospice care, on 11/18/2018 R2 was discharged from hospice services due to extended prognosis. On 02/07/2019 R2 was observed with very poor appetite, increased confusion, was diagnosed Senile Brain Degenerative Disease and was placed on Hospice care. On 02/21/2019 R2 was reported as having no pain, on continuous oxygen and non-responsive to stimuli during a routine hospice visit. On 02/22/2019 medical records indicate that R2 died and that Cardiopulmonary Arrest and Senile Degeneration of the Brain as the direct causes of death. On 10/01/2020 S1 stated that “R2 was never in pain, I never needed to help administer pain medication to them.”, S2 stated “I never provided R2 with pain medications.” Regarding the allegation: “Staff over medicated resident” 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. Regarding the allegation: Resident developed rash while under the care of the licensee. On 03/09/2020 the department received an allegation that staff neglected to change R3’s diapers in turn R3 developed skin rash. On 03/10/2020 3 out of 4 residents interviewed did not have any concerns regarding the care and supervision being provided to them by the staff. 1 out of 4 residents was not available for an interview. R3 stated that they had no complaints against the staff, R3 acknowledged having a small wound on their buttocks and right foot, but said that their doctor and nurse comes to treat them, R3 also stated that their family is aware of the wounds and sees to it that they get proper care. Witness W1 stated that they had no complaints or concerns with the care and supervision provided to R3 and that R3 had wounds when they were at the hospital but believes that the wounds have healed since. Regarding the allegation: Resident developed rash while under the care of the licensee. 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. Regarding the allegation: Staff fabricated resident records. 03/09/2020 the department received an allegation that the Administrator falsified documents indicating that resident R1 was turned and reposition when R1 was supposed to. On 10/02/2020 the administrator stated that they could not find the turning and repositioning log, they were not able to contact a former staff S3 who oversaw the log. On 10/05/2020 LPA conducted record reviews of R1’s resident records and did not observe records of staff assisting R1 with turning and repositioning. Regarding the allegation: Staff fabricated resident records. 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. Regarding the allegation: Staff is rough with resident. 03/09/2020 the department received an allegation that Staff S4 would pull resident R4 on their wrist when transferring causing pain to the resident. On 03/10/2020 3 out of 4 residents interviewed did not have any concerns regarding the care and supervision being provided to them by the staff, 1 out 4 residents was not available for an interview. R3 stated that they have not seen staff mistreat any residents. Witness W2 stated that they have not seen staff do anything that they felt was wrong around any of the residents. Staffs S1 and S2 stated that they provided R4 with assistance in transferring from their bed to their wheelchair and back by holding them in their hips and waistband while R4 is holding onto their shoulders. On 10/01/2020 the administrator stated that staff S4 was no longer employed at this facility, S4 did not return to work after going on a vacation around March of 2020. Regarding the allegation: Staff is rough with resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. An exit interview was conducted. A copy of this report rights was provided.the state’s words, verbatim · CDSS document, Oct 7, 2021 · control 11-AS-20200309132542

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Oct 8, 2021

Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on IB’s investigation the licensee failed to ensure that persons with stage 3 and 4 pressure injuries are not retained in a residential care facility for the elderly. R1 who had unstageable and stage 3 pressure injuries was retained at the facility which posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2021

Plan of correction: The licensee will conduct a training about Title 22 Regulation 87615(a)(1) Prohibited Health Conditions. Proof of correctiion will be submitted by POC due date. Civil Penalities were assessed please see LIC421IM.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Case Management - Deficiencies visit and met with administrator Minda McNamara. The purpose of this visit is to cite on deficiencies observed during investigations that were conducted on the complaints with control numbers 11-AS-20200312105209 and 11-AS-20200309132542. Based on investigations by the departments Investigations Branch (IB), the administrator Rosendo Carlo Miranda retained resident R1 at the facility while having prohibited health conditions. Record reviews conducted by LPA Coronel indicate that there were no incident reports submitted within seven days of R1's hospitalization's on 02/19/2020 and 02/28/2020. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D. An exit interview was conducted, plans of corrections were discussed. A copy of this report and appeals rights were provided.the state’s words, verbatim · CDSS document, Oct 7, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Oct 8, 2021

Administrator - Qualifications and Duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on IB's investigation the licensee failed to ensure that the administrator had the knowledge and ability to conform to Title 22 Regulation 87615(a)(1) Prohibited Health Conditions, R1 was retained at the facility while having prohibited health conditions this posed an immidiate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2021

Plan of correction: The licensee will review Title 22 Regulation 87405(d)(2) Administrator - Qualifications and Duties. Proof of correction will be submitted by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(B) · Plan of correction due date: Oct 14, 2021

Reporting Requirements. Each licensee shall furnish to the licensing agency ...following: A written report shall be submitted... within seven days of the occurrence of any of the events... below. This ...case. Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by: Based on record reviews the licensee failed to ensure that written reports of serious injuries were submitted within 7 days, R1's hospitalization events were not reported to the department which posed potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2021

Plan of correction: The licensee will conduct training and review Title 22 Regulation reporting requirment 87211(a)(1)(B) Reporting Requirements. Proof of correction will be submitted by POC due date.