Senior Manor Care

Allegation investigated: Staff failed to provide resident records, medical records, x-rays, color and/or black and white photographs and billing records.

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 Gloria Somintac, House Manager. The investigation consisted of following: Interviews and Record reviews. On 05/05/23, LPA Soto interviewed S#1 – S#3, R#2 – R#7. LPA requested and received the following documents on 05/05/23: Resident Roster, Staff Schedule. LPA also requested copy of R#1 file, Admissions agreement, ID/Emergency information, copy of 1st rent receipt, Preplacement appraisal information, Appraisal/Needs and Services Plan, Resident Appraisal, Personal Property page, Mars (June, July, August 2021) Consent for emergency medical treatment, Physician’s report, and Hospital records (Newport hospital and legend home health.) Witness provided copy of request and delivered tracking notice. Substantiated Based on the LPA's investigation, the investigation revealed the following. Allegation – Staff failed to provide resident records, medical records, x-rays, color and/or black and white photographs and billing records. Interviews with S#1 – S#3, communicated that they did not receive any request for records for resident. S#1 communicated that S#1 has been working at the facility a little over a year. They did not receive any request for records by mail or any other way. S#2 & S#3, communicate that S#2 had been in vacation, so S#2 did not see or get any request for records for resident. S#3 does not supervise facility, so, S#3 did not have knowledge of ever receiving any request for records for resident. LPA reviewed records provided by witness, where it demonstrates request package was delivered by United Parcel Services on 04/19/23 to facility address. Facility failed to provide copy of requested file within 2 business day as per TITLE 22 regulations. LPA’s records review did concur with the above allegation. Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation. An exit interview was conducted with Gloria Somintac, House Manager and a hard copy of report was provided along with Appeal rights.the state’s words, verbatim · CDSS document, Jun 18, 2023 · control 11-AS-20230427112028

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jul 3, 2023

To have prompt access to review all of their records and to purchase photocopies of their records.....This was not as evidence by: based on facility failing to provided requested records within 2 business day as per TITLE 22 regulations.the state’s words, verbatim · CDSS document, Jun 18, 2023

Plan of correction: Adminsitrator to provide complete file to attorney. Send proof of delivered file to LPA.

Allegation investigated: Facility staff failed to supervise resident resulting in the resident wandering away from the facility.

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 Gloria Somintac, House Manager. The investigation consisted of following: Interviews and Record reviews. LPA Soto conducted interviews with S#1 - S#3, R#1 - R#6, and W#1. The LPA also requested copies of the following documents: Resident roster and Staff roster. Administrator never provided Incident report and/or Incident Report # from LASD-LOMITA. Substantiated Based on the LPA's investigation, the investigation revealed the following. Allegation – Facility staff failed to supervise resident resulting in the resident wandering away from the facility. Interviews with S#1 – S#2, communicated that they were not at the facility at the time resident left the facility unsupervised. S#1 wasn’t working at the facility at the time of the incident. S#2 had the day off and wasn’t at the facility at the day of the incident. S#3 communicated that S#3 did not recall what exactly happened the day the resident left the facility unsupervised. S#3 recalled that resident was a wanderer. The day resident left the facility unsupervised they had 2 new care givers working that day, they are no longer working at the facility. He believed one was in the garage doing laundry and the other care giver was helping a resident. They heard the egress signal go off and they both went to see who had opened the door. S#3 believes they checked the facility and found that one resident was no longer at the facility. They walked around the neighborhood, local stores, and restaurants looking for the resident. They could not locate resident, so they called 911 to report resident missing. When LASD arrived at the facility take the report, they informed S#3 that they had found resident, resident had gone back to resident original home. Apparently, resident had gotten into an uber and ended at resident original home. No one knows how resident was able to get an uber and give their address to have them take resident there. Interview with witness communicated that W#1 was outside of their home when they saw resident pull up in front of their home. W#1 recognized resident and was asked by UBER driver, “If they knew the passenger” and W#1 told them yes. W#1 contacted resident’s family and kept resident with them until resident’s family came to get resident. Interviews conducted did concur with the above allegation. Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued a citations. An exit interview was conducted with Gloria Somintac, House Manager and a hard copy of report was provided along with Appeal rights.the state’s words, verbatim · CDSS document, Jun 18, 2023 · control 11-AS-20230516150239

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(D) · Plan of correction due date: Jul 1, 2023

Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This was not met as evidence by: based on resident wandered out the facility unsupervised which poses a health and safety risk for all persons in carethe state’s words, verbatim · CDSS document, Jun 18, 2023

Plan of correction: Administrator to conduct a training session on how to avoid having resdient leave the facility without supervision. Send training and log with signatures to LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 1, 2023

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This was not met as evidence by: Based on based on resident wandered out the facility unsupervised. Which poses a health and safety risk for all persons in carethe state’s words, verbatim · CDSS document, Jun 18, 2023

Plan of correction: Administrator to conduct a training session on how to avoid having resdient leave the facility without supervision. Send training and log with signatures to LPA.

Allegation investigated: Facility floor in resident room is in disrepair.

This report supersedes report dated 12/01/22. 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 Gloria Somintac, House Manager The investigation consisted of following: Interviews and Record reviews. On 12/01/2022, LPA Soto interviewed S#1 - S#3, R#1 -R#6. LPA toured the entire facility. LPA observed in room #4, that floor boards where bubbling up, seemed as if they had water damage from underneath the floor. LPA requested and received the following documents on 12/01/22: Resident Roster, Staff roster, and Repair Invoice. Based on the LPA's investigation, the investigation revealed the following. Substantiated Allegation: Facility floor in resident room is in disrepair. Interviews with S#1 & S#3, communicated that maintenance had come last week to fix some pipes under the house and were suppose to come back and fix the floor. S#1 informed management about the floor needing repair, but management did not give S#1 a time frame when they would be coming back to fix the floor. S#2 communicated that S#2 wasn't sure if he was told about the floor needing repair. Interview with R#1 & R#4, communicated that the floor in room #4 has the floor bubbling up and it's unstable. It's been like that for a few days. They couldn't recall the exact day it occurred. LPA observed the floor in room #4 and it looks like it had water damage and that's why it was bubbling up and it's unstable. When LPA tested the damage floor, it bounced up and down. The floor has about 2 x 2 sq feet of damage. It does look unstable. LPA also reviewed the invoice when the maintenance company came out to fix the plumbing, it was on 11/26/22. The facility was aware and fixing the issue. Management has called maintenance company to come out today to fix the floor. Even though, the facility fixed part of the floor issue, it's still in disrepair. The interviews conducted and records reviewed did concur with the above allegation. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation. An interview was conducted with Gloria Somintac, House Manager and a hard copy of report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 10, 2023 · control 11-AS-20221130122812

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 17, 2023

87303(a) -The facility shall be clean, safe, sanitary and in good repair at all times...This was not met as evidence by: Based on room floor bubbling.the state’s words, verbatim · CDSS document, Mar 10, 2023

Plan of correction: Administrator to repair and send copy of repair invoice to LPA on or before POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Gloria Somintac, House Manager and the purpose of today’s visit was explained. There are currently (5) residents in the facility. (1) residents are ambulatory, (4) 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 in the attached garage. LPA and Gloria toured the entire inside of facility. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. 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 hall closet. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings 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 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. No technical Advisory (TA) issued. An exit interview conducted with Gloria Somintac, House Manager and a hard copy of report provided.the state’s words, verbatim · CDSS document, Feb 27, 2023

Allegation investigated: Staff are not wearing PPE

On 01/25/2023 Licensing Program Analyst (LPA) Alvizar conducted a visit at this facility to deliver complaint investigation findings. LPA met with House Manager, Gloria Somintac and the purpose of the visit was explained. LPA conducted COVID -19 risk assessment at the front door with Caregiver, Jay Fernandez. Jay said there is no COVID here. Upon entery, LPA observed staff #1 and #2 not wearing a mask. On 08/26/22 Licensing Program Analyst (LPA) Antonia Alvizar conducted a initial complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Gloria Somintac, House Manager. Upon entery, LPA observed staff #1 and #2 not wearing a mask. Investigation consisted of following: Interviews, record review, and observations. LPA Alvizar interviewed House Manager, S#2, R#1 - R#4. Received the following documents on 08/26/22: Resident roster and staff schedule. Toured rooms #1 - #4, dining room, living room, and kitchen. Continue on LIC 9099c Substantiated I Investigation Revealed Regarding the allegation: “Staff are not wearing PPE”. During interviews conducted on 08/26/2022, it revealed the following: 1 out of 4 residents disagree with the allegation, resident R#1 stated, "No, they do keep up with the mask". 1 out of 4 residents agreed the with allegation, resident R#3 stated, “Yes, they don’t wear their mask” 2 out of 4 residents stated sometimes about the allegation, R#4 stated, “Sometimes, I see staff putting their mask on a lot” 0 out of 2 staff disagree with the allegation, 2 out of 2 staff agreed with the allegation, staff S#1 stated, “Yes, we are not wearing PPE”. Based on LPA observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency. An exit interview was conducted with Gloria Somintac, House Manager a hard copy of report and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Jan 25, 2023 · control 11-AS-20220823160104

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 25, 2023

87468.1(a)(2) 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,... Based on observations and interviews staff were not wearing a mask. Which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 25, 2023

Plan of correction: Administrator will instruct and perform training with all staff on when and how to wear mask while working at facility. Administrator will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC due date: 02/07/2023

Allegation investigated: Facility floor in resident room is in disrepair.

Licensing Program Analyst (LPA) Ana Soto conducted an initial complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Gloria Somintac, House Manager The investigation consisted of following: Interviews and Record reviews. On 12/01/2022, LPA Soto interviewed S#1 - S#3, R#1 -R#6. LPA toured the entire facility. LPA observed in room #4, that floor boards where bubbling up, seemed as if they had water damage from underneath the floor. LPA requested and received the following documents on 12/01/22: Resident Roster, Staff roster, and Repair Invoice. Based on the LPA's investigation, the investigation revealed the following. Allegation: Facility floor in resident room is in disrepair. Interviews with S#1 & S#3, communicated that maintenance had come last week to fix some pipes under the house and were suppose to come back and fix the floor. S#1 informed management about the floor needing repair, but management did not give S#1 a Unsubstantiated a time frame when they would be coming back to fix the floor. S#2 communicated that S#2 wasn't sure if he was told about the floor needing repair. Interview with R#1 & R#4, communicated that the floor in room #4 has the floor bubbling up and it's unstable. It's been like that for a few days. They couldn't recall the exact day it occurred. LPA observed the floor in room #4 and it looks like it had water damage and that's why it was bubbling up and it's unstable. When LPA tested the damage floor, it bounced up and down. The floor has about 2 x 2 sq foot of damage. It does look unstable. LPA also reviewed the invoice when the maintenance company came out to fix the plumbing, it was on 11/26/22. The facility was aware and fixing the issue. Management has called maintenance company to come out today to fix the floor. The interviews conducted and records reviewed 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 interview was conducted with Gloria Somintac, House Manager and a hard copy of report was provided.the state’s words, verbatim · CDSS document, Dec 1, 2022 · control 11-AS-20221130122812

Allegation investigated: Facility is not addressing issues with insects.

This amended report supersedes report dated 08/15/22. 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 Gloria Somintac, House Manager. The investigation consisted of following: Interviews, Record reviews, and tour of entire facility inside and out. On 08/15/22, LPA Soto interviewed Administrator, S#2, & S#3, R1 - R#3. LPA Soto received the following documents on 08/15/22: Resident roster, Staff roster, Estimate invoice for facility repairs. Based on the LPA's investigation, the investigation revealed the following. Allegation 1 - Facility is not addressing issues with insects. Interviews with S#1, S#2, R#1, & R#2, they all agreed that the facility has had ants. The staff began to treat the entire facility by spraying (Raid.) LPA inspected the entire facility and found dead ants in room #2 and kitchen. In room#4 the staff had placed 4 ant baits to treat the ants. The facility is addressing the issue with the insects. The interviews and inspection conducted did not concur with the above allegation. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 26, 2022 · control 11-AS-20220812094827

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility is in disrepair. Facility is not addressing issues with insects.

Licensing Program Analyst (LPA) Ana Soto conducted an initial complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Gloria Somintac, House Manager. The investigation consisted of following: Interviews, Record reviews, and tour of entire facility inside and out. On 08/15/22, LPA Soto interviewed Administrator, S#2, & S#3, R1 - R#3. LPA Soto received the following documents on 08/15/22: Resident roster, Staff roster, Estimate invoice for facility repairs. Based on the LPA's investigation, the investigation revealed the following. For Allegation – Facility is in disrepair. Interviews with Administrator, S#2, S#3, R#1 - R#3, they all agreed that the facility was in disrepair. The floor broads needed to be repaired. The walls were scratched and had paint peeling. The outside ramp which stretches the back side of the facility is broken. LPA inspected the enitre facility. LPA found that R#1 has the wooded window seal broken. The back yard ramp stretching the back side of the facility is unsafe to walk on or transport anyone on it. Substantiated Room #4, West-side & East-side walls are scraped/scratched and have paint peeling. The door frame on the west side has scratches and paint peeled off, Main door bottom half has scratches and paint peeled off. The floor boards near west side wall and south wall have broken and missing slats of wood. The doorway leading to the restroom needs a wooden slat to be replaced. The kitchen cabinets have dirt, grease, and need to be cleaned and painted. The living room ceiling has water mark stains from previous water damage. Interviews and inspections conducted did concur with the allegation above. Allegation #2 - Facility is not addressing issues with insects. Interviews with S#1, S#2, R#1, & R#2, they all agreed that the facility has had ants. The staff began to treat the entire facility by spraying (Raid.) LPA inspected the entire facility and found dead ants in room #2 and kitchen. In room#4 the staff had placed 4 ant baits to treat the ants. The interviews and inspection conducted did concur with the above allegation. Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued a citations. An exit interview was conducted with Gloria Somintac, House Manager a hard copy of report was provide and Appeal Rights.the state’s words, verbatim · CDSS document, Aug 15, 2022 · control 11-AS-20220812094827

From the deficiency page — Deficiency type: Type B · Section cited: CCR 873039a) · Plan of correction due date: Sep 5, 2022

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 evidence by: Based on specific areas of facility needed paint, repair and replacement floor boards. Which poses a potential healtha dn safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 15, 2022

Plan of correction: Administrator to repair, paint, clean and/or replace any material needed to fix problems. Provide pictures of repairs and copy of invoice of repairs completed on or before POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 19, 2022

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 evidence by: Based on ants in the kitchen room #2 & room #4. Which poses a potential healtha dn safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 15, 2022

Plan of correction: Administrator to treat facility for insects. Provide pictures of treament products used to treat facility on or before POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA's ) Ana Soto and Jeremiah Randle conducted an unannounced Annual required visit and an infection control inspection to the above facility. LPA was met by Gloria Somintac and later spoke with Stephen Gradney via telephone and the purpose of today’s visit was explained. There are currently (4) residents in the facility. (0) residents are ambulatory and (4) are non-ambulatory and bedridden. The facility is a single-story structure located in a residential neighborhood. It has a ramp that goes along the east and west side of the facility. The facility consists (5) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry room and attached garage. LPA's and house manager toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (2) bathrooms are clean and operational. First aid kit complete with manual; smoke detectors and carbon monoxide detector are inter-connected 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. 2 staff files were complete and current. 2 resident files were complete and current. 1 resident mars was not signed for their daily doses. 1 resident mars was complete and current Ample supply of perishable and nonperishable food, hot water temperature is 115 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 on counter next to kitchen. 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 are logged, and temperature checked, sanitizer/soap in the staff bathroom and additional sanitation supplies are locked in the garage. LPA observed staff and clients wearing masks, residents’ private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The facility has an approved Mitigation plan. The resident’s temperatures are checked and logged twice a day. PPE's are enough for 30 days. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation. An exit interview conducted with Gloria Somintac, House Manager and a hard copy of report provided along with Appeal Rights.the state’s words, verbatim · CDSS document, Mar 21, 2022

Allegation investigated: Staff are not assisting resident with managed incontinence.

On 11/23/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced 10day complaint visit at this facility. LPA met with Staff Gloria Somintac and explained the purpose of today's visit is to gather information of the allegation mentioned above. Administrator Steven Gradney arrived later and joined the visit. The investigation consisted of the following: LPA inquired questions relevant to the nature of the complaint. LPA Lourdes Montoya conducted interviews with Staff (S1-S3) and resident (R1) on 11/23/2021. LPA was unable to interview Residents (R2-R5) because R2 left during the visit, R3 has a hearing problem, R4 was asleep and R5 has a dementia. A tour of the facility’s outside and inside grounds was conducted. LPA obtained residents’ (R1) service records, residents’ (R2-R5) physician’s reports; facility roster, and staff roster. Report continued in LIC 9099C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff are not assisting resident with managed incontinence. It is alleged facility staff are not assisting resident with managed incontinence.The complainant reported facility care providers are not changing the resident's diaper in a timely manner. Based on record review, Resident's (R1) physician report shows she has no bowel and bladder impairment and she is able to manage her own toileting needs. Interview with R1 and staff (S2-S3) revealed R1 is not incontinent but because she is unable to get up and walk independently, she uses diaper for urination and defecation. Therefore, she needs assistance in changing her diaper. R1 stated in interview that she waits for ten (10) to fifteen (15) minutes for staff to change her diaper and sometimes when staff are too busy, she waits for thirty (30) minutes. Nevertheless, R1 disclosed she thinks the wait time is reasonable. R1 revealed staff are providing quality care and she is happy living in this facility. Based on LPA's record review, R3, R4 and R5 are unable to care for their own toileting needs but LPA was unable to obtain information about their incontinence needs because LPA was unable to interview them. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, "Staff are not assisting resident with managed incontinence" did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited and exit Interview was conducted with Administrator Steven Gradney. LPA Montoya was unable to furnish a hard copy of the report due to a technical issue. A copy of the report was emailed to Administrator Steven Gradney.the state’s words, verbatim · CDSS document, Nov 23, 2021 · control 11-AS-20211119150306

Type of visit: Case Management - Deficiencies

On 11/23/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit. LPA was greeted by Staff Gloria Somintac and soon later Licensee/Administrator Steven Gradney joined the visit. LPA observed deficiencies while conducting a 10-day complaint visit on 11/23/2021. LPA observed and took photos of of the following areas in the facility that need repair: 1. Kitchen cabinet - LPA Montoya did not observe a cover of a bottom kitchen drawer. 2. Clogged sink - LPA observed the sink in the common bathroom is clogged 3. Broken ramp - LPA observed the ramp covered with turf in the backyard is broken. LPA looked under the turf and discovered the wooden ramp is broken. California Code of Regulations, Title 22, Division (6) and Chapter (1) is being cited on the attached LIC 809D. Exit Interview was conducted and appeal rights were explained. LPA was unable to furnish a copy of the report due to a technical issue. A a copy of this report was emailed to Administrator Steven Gradney.the state’s words, verbatim · CDSS document, Nov 23, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 3, 2021

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 evidenced by: On 11/23/2021, LPA observed a cover for a kitchen drawer is missing, bathroom sink is clogged, and a ramp in the backyard is broken. This poses a potential Health, Safety and/or Personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 23, 2021

Plan of correction: Licensee/Administrator shall repair the drawer, sink and the ramp by the POC due and email proof of corrections to Lourdes.Montoya@dss.ca.gov

Allegation investigated: Resident(s) not administered medication as prescribed by physician. Facility is in disrepair.

On 11/16/2021 around 09:00am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Steven Gradney. The Investigation consisted of the following: On 11/16/2021 LPA Calderon interviewed S1 for complaint. On 11/16/2021 LPA Calderon interviewed S2-S3 for complaint. On 11/16/2021 LPA Calderon attempted to interview R1-R5, only R1 – R2 could answer any questions due to dementia. On 11/16/2021 LPA Calderon reviewed MAR for R1-R5, reviewed admission agreement for facility and reviewed S2-S3 employee files. LPA Calderon reviewed R2 admission agreement and resident file for complaint. On 11/16/2021 LPA Calderon and Administrator Gradney toured the physical plant. The investigation revealed the following: Unsubstantiated Allegation 1: Resident(s) not administered medication as prescribed by physician. On 11/16/2021 LPA Calderon interviewed S1 for complaint, S1 states that S1 was not aware of any issues with S1 facility and states that if there are any issues with the care of S1 residents or the facility, S1 will take care of any issues the same day. On 11/16/2021 LPA Calderon interviewed S2-S3 both staffs state that they give the right medication on time and in the right amount and update the residents MAR. Staff states that they follow the prescribed doctors’ orders for resident’s medication and if there is a change, or different amount they update the residents MAR. On 11/16/2021 LPA Calderon interviewed R1-R2, R1 states that staff gives the right medication but from time to time are late with the giving the medication, but has no issues with the care given, R2 states that there are no issues with the medication given. On 11/16/2021 LPA Calderon reviewed MAR for R1-R5, and there does not appear to be any issues with the documentation for residents’ medications and all times and dates are filled out for the past 5 months. Allegation 2: Facility is in disrepair. On 11/16/2021 LPA Calderon interviewed S1-S3 and all state no issues or concerns with the facility and there are no safety issues. On 11/16/2021 LPA Calderon interviewed R1-R2, but state that the facility is safe, well maintained and they have no issues with the facility or living in this home. On 11/16/2021 LPA Calderon and Administrator S1 toured the facility, LPA Calderon checked electric outlets and the physical plant. There does not appear to be any issues with the facility and the facility is well maintained and LPA Calderon could not find any issues. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of residents not administered medication as prescribed by physician, and facility is in disrepair is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator (Steven Gradney).the state’s words, verbatim · CDSS document, Nov 16, 2021 · control 11-AS-20211110150940