St Matthews Home for the Elderly II

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) V. Maldonado made a subsequent visit to the facility for the purpose of completing the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with caregiver, Nenita Capistrano and explained the purpose for the visit. During today's visit, LPA Maldonado observed the following: At 10:14AM, (4) staff files were reviewed for required documentation. It was discovered that Staff# 1-2 (S1-S2) files did not have health screenings and proof of completed required annual training. It was also discovered that files for Staff# 3-5 (S3-S5) were not available for LPA to inspect. Per S1, files for S3-S5 are with S3 and S3 is currently on vacation. At 10:20AM, S1 confirmed with LPA that S4-S5 are currently employed at the facility and their work schedule is 7AM-7PM, Saturday and Sunday, but may sometimes alternate depending on the need for staff. After review of the Facility Personnel Report Summary, it was noted that S4-S5 are not associated to the facility. LPA Maldonado was also unable to determine who the administrator for the facility is, as per licensing records, Rebecca Sinclair is listed as the Administrator, but staff Michelle Aguirre has informed LPA during the annual inspection in 2022 that she is the Administrator. The licensing agency has not been provided records to request a change in administrator, and there is no proof of a current and valid administrator certificate at the facility or file for an administrator available for LPA to inspect. Six (6) resident medications and Centrally Stored Medication and Destruction Records were inspected and reviewed. It was determined that medications are documented properly and administered as prescribed. (Report Continued on LIC809-C...) LPA attempted to conduct interviews with (6) residents, however was unable to due to cognitive impairments, unresponsive to LPA, and/or sleeping. (2) staff interviews were conducted with available staff. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit and will be cited on the LIC809-D pages. Additionally, Immediate Civil Penalties will be issued in the amount of $1,500 were issued today, for repeat violations within a 12-month period and for staff who are not associated and working at the facility. An exit interview was conducted with caregiver Nenita Capistrano and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 8, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with caregiver, Nenita Capistrano and explained the purpose for the visit. Administrator, Michelle Aguirre was phoned and notified of the visit.. The facility is licensed to serve (6) elderly adults, ages 59 and above. It is approved for (6) non-ambulatory residents, of which (1) may be bedridden and reside in bedroom# 3 only. The facility also has a hospice waiver approved for (2). The facility is a single-story home, located in a residential area. The home consists of (4) resident bedrooms, (2) resident bathrooms, (1) visitor bathroom, a kitchen, living room, dining room, tv room, attached garage, and a fenced pool. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention. During today's visit, LPA Maldonado obtained a copy of the client and staff roster, and conducted a tour of the physical plant with assistance of caregiver Nenita. The following was observed: One central entry point for universal entry screening Sufficient PPE stored for 30-days and readily available for use, throughout the home and stored in the garage Physical plant inside and outside is clean, sanitary and in good repair All walkways and pathways observed to be free of obstruction/hazards (Report Continued on LIC809-C...) All resident bedrooms had the required furniture and the bedding had the required linens Additional linens were observed in a linen closet in the hallway, inspected and in good repair. Cleaning supplies and toxins were observed locked and inaccessible in the laundry room Each client bathroom was equipped with a toilet, shower, and wash basin- all operational and in good repair. Showers had the required grab bars and non-skid mats The water temperature was tested and measured at 105.6*F in bathroom# 1 and 106.7*F in bathroom# 2 Sharps and knives were stored inaccessible in a closet near the kitchen. At 1:30PM, LPA observed 2 kitchen knives and a pair of scissors in a drawer in the kitchen next to the sink where resident utensils are stored. Caregiver Nenita stated they're left there throughout the day and are placed back in the closet at the end of the day. LPA told her they should be inaccessible to residents at all times and she quickly placed them in the closet, locked and inaccessible. At 1:31PM, Food supplies was inspected and LPA observed a quarter gallon of milk, one bottle of juice, a few yogurts and jellos, a few vegetables, and less than 24 eggs in the fridge- facility not in compliance with 2-day of perishables avilable for 6 residents in care Dried and canned foods were observed and facility in compliance with 7-day non-perishables for 6 residents in care Kitchen was observed clean/sanitary, and flatware, utensils, and cups were available and in good repair- sufficient for clients in care All the required postings were posted throughout the home The washing machine and dryer were observed in the garage and clean and operational at the time of the visit 3 fire extinguishers were observed throughout the facility, fully charged with current inspections At 1:43PM, LPA discovered that a closet located inside of Resident#6's private bedroom, was converted into a staff room. According to caregiver Nenita, staff rest there. The closet room is equipped with a bed, a TV, and storage space above the bed that has folded clothing throughout. It appears someone is occupying the room long-term. At 1:45PM, LPA observed a padlock on the gate located on the side of the house that leads to the street. Caregiver was asked why the gate was locked, to which she responded that it is to keep wildlife out of the home. The facility does not have fire clearance for locked perimeters. At 2:01, (6) resident files were reviewed, LPA found that files were not complete and were missing Admissions Agreements, Needs and Services Plans, Physician's Reports, and Pre-Placement Appraisals It was discovered that (3) residents are currently on hospice, and the facility only has a waiver approved for (2) It was also discovered that (6) residents have bedrails on their beds, however, only (3) have written orders indicating the need for them. Per California Code of Regulations, Title 22, deficiencies were observed and will be cited during today's visit. Due to time constraints, LPA was unable to complete the annual inspection and will return at a later time to complete it and issue Civil Penalties for repeat violations within a 12 month period. An exit interview was conducted with caregiver Nenita Capistrano, and copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 7, 2023

Type of visit: POC

Licensing Program Analyst(s)(LPA) Mary Flores and Nune Margaryan conducted an unannounced Plan of Correction (POC) visit regarding deficiencies noted on 8/22/23. On 8/22/23 LPA Flores conducted a complaint investigation visit and noted the following deficiency: Section CCR 87468.1(a)(2) Personal Rights of Residents in All Facilities: On 8/22/23 LPA requested training provided to staff between September 2022 and February 2023 regarding COVID 19 protocols and LIC 9098 certifying to adhere to 87468.1(a)(2) signed by licensee to be submitted by POC due date 8/23/23. Documents were not received by the department by POC due date. *Civil Penalties were assess for $700 dollars.* On 8/22/23 LPA Flores conducted a case management visit -deficiencies and noted the following deficiency: Section CCR 87411(c)(6) Personnel Requirements - General: On 8/22/23 LPA requested licensee to certify on LIC 9098 that files will be available for review at the facility and submit LIC 9098 and trainings provided between September 202 and February 2023 by POC due date 8/29/23. Documents were not received by the department by POC due date. *Civil Penalties were assess for $100 dollars.* *Civil Penalties were assess for a total of $800 dollars during this visit.* Exit interview was conducted and a copy of this report and Civil Penalties were provided.the state’s words, verbatim · CDSS document, Aug 31, 2023

Allegation investigated: Facility is not following Covid-19 safety protocols.

Licensing Program Analyst(s) (LPA) Mary Flores conducted a subsequent unannounced complaint investigation visit regarding the above allegation. LPA Flores met with Nenita Capistrano Caregiver and explained the reason for the visit. The investigation consisted of the following: On 11/3/22 LPA Flores conducted a complaint investigation visit. LPA conducted a tour of the facility, interviewed residents #1-#6 (R1-R6), and staff #1-#2(S1-S2). On 1/18/23 LPA Flores contacted Michelle Aguirre to follow up on requested documents: staff roster, Caregiver schedules for the month of September, October, and November 2022, Trainings or In-services provided during 2022, Visitor’s log for September, October, November 2022 via email. On 8/22/23 LPA Flores delivered findings at the facility. The investigation revealed the following: Regarding allegation: Facility is not following Covid-19 safety protocols. (CONTINUED LIC 9099C) Substantiated It is alleged, on 9/30/22 a witness observed a caregiver not wearing a mask or put a mask during the visit or while providing care to the residents. Staff did not screen representative for symptoms or have a sign-in procedure. Interviews with residents revealed, 1 out of 6 residents stated staff wears mask when providing direct care. 5 out of 6 residents were unable to answer due to cognitive skills. Interviews with staff revealed 2 out of 2 staff stated to wear a face mask while providing care. On 11/3/22 LPA Flores arrived at the facility at 9:10am and was allowed entry to the facility without being screen by S1. S1 was wearing a surgical mask under their chin, not covering the mouth or nose throughout the visit. LPA conducted a tour of the facility with S2, observed screening area to the right-hand side of entry door with visitor's log, hand sanitizer, and surgical mask, signs are posted by the entry area for symptoms, proper hand washing, and check for symptoms signs. PPE supplies were observed. at 9:40-10:00am LPA was requested to sign-in the visitor's log and staff roster, caregiver schedules, and staff files for review, which were not available at the facility for review. Documents were not available for review. LPA requested documents be email. On 1/3/23 LPA followed up via email requesting documents, documents were not provided to LPA. Per PIN 23-07 ASC, the masking requirements came to an end on March 3, 2023. Therefore, staff were required to properly use a face mask while at the facility. PIN 22-28 ASC Screening Protocols are to designate a facility staff to conduct initial screening for COVID 19 symptoms of all individuals entering the facility. During the visit of 11/3/22 LPA did not get screen by staff prior to entering the facility. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report was provided, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 28-AS-20221026153715

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 23, 2023

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on observation licensee did not ensure staff did not wear mask properly as observed on visit conducted on 11/3/22 which poses an immediate risk to the health, safety, personal rights to the persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2023

Plan of correction: Administrator will submit training provided to staff between September 2022 and February 2023 regarding COVID 19 protocols and will submit LIC 9098 certifying to adhere to 87468.1(a)(2) signed by licensee by POC due date 8/23/23.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit. LPA met with Nenita Capistrano caregiver and explained the reason for the visit. On 11/3/22 LPA Flores conducted an unannounced complaint investigation visit. During this visit LPA requested Administrator Michelle Aguirre to email the following documents: staff roster, Caregiver schedules for the month of September, October, and November 2022, Trainings or In-services provided during 2022, Visitor’s log for September, October, November 2022, as they were not available for review at the facility. On 1/18/23 LPA Flores followed up regarding documents requested, LPA did not received the documents. Deficiencies are being cited under Title 22 Regulations on LIC 809D. Exit interview was conducted with caregiver and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 22, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(6) · Plan of correction due date: Aug 29, 2023

87411 Personnel Requirements - General:(c) All RCFE...(6)The licensee shall maintain documentation pertaining to staff training in the personnel records, ... For on-the-job training,.. This requirement is not met as evidence by: Based on document review and observation licensee failed to ensure staff #1 and #2 files were available for review during the visit conducted on 11/3/23 and to provide documents after which poses a potenital risk to the health, safety, personal rights of the persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2023

Plan of correction: Administrator will certify on LIC 9098 that files will be available for review at the facility and will submit the requested trainings to the department by POC due date 8/29/23.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit at the facility during a complaint investigation visit on 11/3/22 to note deficiencies. LPA Flores spoke with Assistant Administrator Michelle Aguirre and explain the reason for the case management. On 11/3/22 LPA Flores arrived at the facility at 9:10am and conducted a complaint investigation visit. At 10:02am LPA Flores contacted Assistant Administrator over the phone and requested a copy of staff roster, caregiver schedules, and staff files for review. Files were not available at the facility for review at the time of the visit. LPA asked Assistant Administrator Michelle Aguirre over the phone if she would be able to provide the documents for review while LPA is at the facility and conducted the investigation. Assistant Administrator stated to be dealing with an emergency and is unable to provide the documents at the time of the visit to leave an email address and she will email the documents to LPA. Deficiency is noted on LIC 809D per Title 22 Regulations. Exit interview was conducted at 11:15am with Nenita Capistrano - Caregiver and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 3, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(f) · Plan of correction due date: Nov 7, 2022

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidence by: Based on observation Licensee did not ensure personnel records are available at the facility for licensing agency to review fjor all staff which poses a potential health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Nov 3, 2022

Plan of correction: Licensee will ensure files are maintain at the facility or accessible and will provide a copy of staff roster, caregiver schedule for the week of 09/26/22 - 11/3/22, staff training on COVID guidelines for the past 6 months, and any COVID related exemption letters for all staff to the department by POC 11/7/22.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) V. Maldonado made an unannounced required 1 year visit to conduct the annual inspection. LPA Maldonado met with caregiver Nenita Capistrano and explained to purpose for the visit. Caregiver phoned assistant administrator Michelle Aguirre and informed her of the visit. LPA used the infection control tool to evaluate the facility. During today's visit, LPA toured the physical plant with caregiver Nenita, food and PPE supplies were observed, COVID-19 procedures were reviewed, staff files were checked for criminal background clearance and training, and residents' medications and files were reviewed for updated emergency information. The facility is licensed for 6 non-ambulatory residents, age range 60 and over -1 may be bedridden and hospice waiver has been approved for 2 residents. Currently there are 6 residents residing in the facility and 4 are on hospice. The assistant administrator Michelle Aguirre arrived at the middle of the visit and assisted with the rest of the visit. The facility consists of 4 bedrooms, 3 bathrooms, a living room, a kitchen, a dining room, a TV room, a backyard with a shaded patio, a body of water was observed in the back yard, and an attached garage. During the tour, LPA observed all walkways, pathways, and entrance/exits free of debris, obstructions, and hazards. There is COVID-19 signage throughout the facility promoting handwashing, social distancing and mask wearing. PPE and hand sanitizer was readily available throughout the facility for resident use. LPA observed the food supplies in the kitchen to be the required 2-day of perishables and 7-day of non-perishables, with a variety of nutritious foods. Medications and sharps were observed to centrally stored and locked in a closet next to the kitchen, inaccessible to residents in care. LPA observed bathrooms#1-#2 to have a working toilet, shower, and wash basin. At 9:17 a.m., bathroom# 2's toilet was observed to not be in good repair as the toilet had no toilet seat or a top pump cover. Bathroom# 2 was also observed to not have a private door and leads to a hallway with a private room. The asst. administrator was asked about this and states the restroom is used only for the one resident with the private room in that area. (Report Continued on LIC809-C...) All bedrooms had the required linens, furniture, and storage space for resident use. The linen closet was observed in the hallway with sufficient additional linens for resident use. The laundry room was observed to have operating machines and in good repair. Cleaning supplies and toxins were also stored in the laundry room, which remains locked and inaccessible to residents in care. A door in the laundry room led to the attached garage which was used for additional storage. Face masks were observed in the garage and additional adult briefs for residents. A fire extinguisher was observed in the kitchen and in the laundry room, operational and fully charged. At 10:22 a.m., LPA reviewed resident files and observed (3) of (6) residents' files to be missing some of the required documents. (2) of (6) dementia care residents do not have an updated physician's report. It was also discovered that there are 2 more residents on hospice than the facility is currently approved for. During review of staff files, LPA observed (2) of (3) resident files to be incomplete and (1) of (3) staff files was not at the facility during the time of the visit. (3) of (3) staff working at the facility during the time of the inspection were found to not be associated to the facility. The administrator was asked about this and states that the 1 staff with no file is only staying here for now. He arrived "last night" and she is not sure if they are going to hire that staff yet. Per Title 22, California Code of Regulations, deficiencies were observed during today's visit and will be cited respectively on the LIC809-D. Immediate Civil Penalties will also be issued in the amount of $500 per each staff (3) that were present and not associated to the facility, during the time of the visit. An exit interview was conducted with assistant administrator Michelle Aguirre and caregiver Nenita Capistrano, and a copy of this report and appeal rights were issued.the state’s words, verbatim · CDSS document, Sep 20, 2022