Springville

Allegation investigated: Staff prohibited resident from having visitors. Staff did not treat resident with dignity or respect. Staff did not keep the facility free from clutter. Staff retaliated against resident due complaints regarding resident care.

*This report will supersede the report dated 07/06/23 to correct specific information on the report* Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met Linda Fan (Administrator) and explained the reason for the visit. The investigation consisted of the following: LPA Mora obtained copies of the resident and staff rosters, interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 - Resident 7 (R1 - R7), and 4 residents' responsible parties, and toured the facility. The investigation revealed the following: regarding the allegation "staff prohibited resident from having visitors", it is alleged that on 2/20/2023, a family member of a resident made an appointment with the facility and showed up with home health nurse and were denied entry to the facility. Administrator and staff denied the allegation. (Continued to LIC 9099-C) Unsubstantiated They stated that this occurred during dinner time and all staff were in the dining room serving the residents. The staff told the family member via phone to wait a bit until they were done so they can go open the outside gate for them. However, the family member call the police right away because they were not provided entry to the facility right away. Residents interviewed could not corroborate with the allegation. Residents' responsible parties interviewed could not corroborate with the allegation and stated they have never had any visitation issues with this facility. The investigation revealed the following: regarding the allegation "staff did not treat resident with dignity or respect", it is alleged that a resident is being discriminated against based on language dialect and receives unfair treatment. Administrator and staff denied the allegation. Residents interviewed could not corroborate the allegation. Residents' responsible parties interviewed could not corroborate with the allegation and stated that during their visits they have not observed staff mistreating or discriminating against residents. The investigation revealed the following: regarding the allegation "staff did not keep the facility free from clutter", it is alleged that there was clutter obstructing the stairwells. Administrator and staff denied the allegation. Staff 1 (S1) confirmed that pieces of furniture were placed there but it was not obstructing the stairway. They were replacing old furniture with new furniture. The old furniture was removed from that spot by end of the day. A picture was attached to this complaint and based on the picture the clutter is not obstructing the stairwell or hallway. It is in an isolated area near the stairway. It is unknown how long the clutter was there. Residents interviewed could not corroborate the allegation. Residents' responsible parties interviewed could not corroborate with the allegation and stated that during their visits they have not observed any clutter and the facility is clean. During today's visit, the LPA did not observed any clutter in the facility and facility was clean. The investigation revealed the following: regarding the allegation "staff retaliated against resident due complaints regarding resident care", it is alleged that a resident's November 2022 eviction notice and limitations on visitation are believed to be retaliatory actions from the facility. Administrator and staff denied the allegation and stated visitation rules applied equally to all visitors. Administrator stated there is no eviction notice issued in November 2022 and that it was a recommendation to the resident's family that the resident might need a higher level of care due to the resident's violent behavior towards staff and other residents. Review of resident's records the only eviction notice found was issued on 01/09/2023 due to non-payment and resident needing higher level of care. Residents interviewed could not corroborate the allegation. Residents' responsible parties interviewed could not corroborate with the allegation. (Continue to LIC 9099-C) Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Oct 26, 2023 · control 28-AS-20230627145047

Allegation investigated: Resident received a pressure injury while in care

Licensing Program Analyst (LPA) Christine Wong met with Staff Kevin Qin who allowed the entry for the facility and explained the reason of the visit. A subsequent visit was conducted to issue an additional citation related to allegation “resident received a pressure injury while in care”. Department review of medical records was completed which revealed systemic failures at the facility in preventing pressure injuries. Immediate $500 civil penalty was issued during today’s visit. At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date. All findings remain the same as indicated on report dated 09/28/23. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Oct 19, 2023 · control 28-AS-20210405152422

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1) · Plan of correction due date: Nov 19, 2023

87405 Administrator - Qualifications and Duties (d)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. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. The requirement was not met as evidenced by Department review of medical records was completed which revealed systemic failures at the facility in preventing pressure injuries which posed a potential risk to residents in riskthe state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator is to reassess all residents in placement and ensure a reappraisal is developed based on residents personal needs and maintained in the residents file for review by the licensing agency. Administrator to submit

Allegation investigated: Resident sustained a fracture due to staff neglect Staff did not seek medical attention for resident in a timely manner

*This is a corrected version of report created on 10/12/23 to correct information provided in the LIC 9099C* On 10/12/23 Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Kevin Qin and explained the reason for the visit. Administrator Linda Fan arrived 10 minutes later. The investigation consisted of the following: On 5/4/23 LPA Ramirez conducted a 24 hour health and safety check. LPA requested the following documents for Resident #1 (R1): Emergency and Information sheet, Physician’s Report dated: 4/19/21, Preplacement Appraisal, Admission Agreement, Discharge documents dated 4/3/23. On 5/4/23, Investigation Bureau Investigator, Christine Ferris was assigned the investigation. Investigator Ferris requested medical records, and conducted interviews with staff, resident. On 7/7/23, A nurse consult was submitted to the Department’s nurse consultant. On 10/12/23 LPA Flores conducted interviews with 3 staff, 3 residents, 2 family representatives and delivered findings. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegations resident sustained a fracture due to staff neglect and staff did not seek medical attention for resident. It is alleged R1 sustained a fracture to the left tibia on 4/29/23 and facility did not call 911. Interviews conducted with administrator and staff revealed the following: On 4/29/23 Staff #1 (S1) assisted R1 with a shower and strapped R1 to the chair to prevent slipping. S1 wheeled R1 in the chair to R1’s bed. S1 stepped outside the room to ask Staff #2 (S2) for assistance transferring R1 to the bed but, S2 was busy at the time. S1 said they returned to the room, “became inpatient” and lifted R1 from the chair, who was still strapped to the chair. R1 was pulled back and fell down along with the chair and S1. Administrator was made aware of the fall. Family representative was contacted by administrator and informed of the fall. Per administrator they monitor R1 between 4/29/23 to 5/1/23 and did not observe bruising, swelling, or indication of pain. On 5/2/23, administrator observed swelling on R1’s left leg. An in-house x-ray was conducted, and results were texted to administrator at around 11:00pm which noted a fracture was found. X-ray Result dated 5/2/23 at 10:47pm notes: Acute fractures of the proximal tibia and fibula. On 5/3/23, R1 was sent to the hospital at around 6:00am. On 6/19/23, administrator stated S1 was aware that a two-person assist was required to transfer R1. As a result, the administrator verbally reprimanded S1. On 5/24/23, investigator attempted to interview R1 and was not able due to cognitive skills. On 5/24/23, interview conducted with S1 revealed, S1 was aware that R1 needed a two-person assist but became inpatient and decided to lift R1 alone. Physician’s report dated 4/29/21 notes R1 is motor impaired and requires continuous bed care. R1 has limited ability to communicate needs and needs assistance with most ADLs (assistance of daily living). Based on LPAs observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustained an acute fracture while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(f); if the department determines the severe body injury of the resident is due to neglect. Exit interview was conducted with Linda Fan and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 16, 2023 · control 28-AS-20230503164443

Allegation investigated: Resident sustained a fracture due to staff neglect Staff did not seek medical attention for resident in a timely manner

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Kevin Qin and explained the reason for the visit. Administrator Linda Fan arrived 10 minutes later. The investigation consisted of the following: On 5/4/23 LPA Ramirez conducted a 24 hour health and safety check. LPA requested the following documents for Resident #1 (R1): Emergency and Information sheet, Physician’s Report dated: 4/19/21, Preplacement Appraisal, Admission Agreement, Discharge documents dated 4/3/23. On 5/4/23, Investigation Bureau Investigator, Christine Ferris was assigned the investigation. Investigator Ferris requested medical records, and conducted interviews with staff, resident. On 7/7/23, A nurse consult was submitted to the Department’s nurse consultant. On 10/12/23 LPA Flores conducted interviews with 3 staff, 3 residents, 2 family representatives and delivered findings. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegations resident sustained a fracture due to staff neglect and staff did not seek medical attention for resident. It is alleged R1 sustained a fracture to the left tibia on 4/29/23 and facility did not call 911. Interviews conducted with administrator and staff revealed the following: On 4/29/23 Staff #1 (S1) assisted R1 with a shower and strapped R1 to the chair to prevent slipping. S1 wheeled R1 in the chair to R1’s bed. S1 stepped outside the room to ask Staff #2 (S2) for assistance transferring R1 to the bed but, S2 was busy at the time. S1 said they returned to the room, “became inpatient” and lifted R1 from the chair, who was still strapped to the chair. R1 was pulled back and fell down along with the chair and S1. Administrator was made aware of the fall. Family representative was contacted by administrator and informed of the fall. Per administrator they monitor R1 between 4/29/23 to 5/1/23 and did not observe bruising, swelling, or indication of pain. On 5/2/23, administrator observed swelling on R1’s left leg. An in-house x-ray was conducted, and results were texted to administrator at around 11:00pm which noted a fracture was found. X-ray Result dated 5/2/23 at 10:47pm notes: Acute fractures of the proximal tibia and fibula. On 5/3/23, R1 was sent to the hospital at around 6:00am. On 6/19/23, administrator stated S1 was aware that a two-person assist was required to transfer R1. As a result, the administrator verbally reprimanded S1. On 5/24/23, investigator attempted to interview R1 and was not able due to cognitive skills. On 5/24/23, interview conducted with S2 revealed, S2 was aware that R1 needed a two-person assist but became inpatient and decided to lift R1 alone. Physician’s report dated 4/29/21 notes R1 is motor impaired and requires continuous bed care. R1 has limited ability to communicate needs and needs assistance with most ADLs (assistance of daily living). Based on LPAs observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustained a subdural hematoma while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(f); if the department determines the death of the client is due to neglect. Exit interview was conducted with Linda Fan and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Staff left resident in a soiled diaper for an extended period of time. It is alleged R1 would smell like urine because R1 wasn’t being changed. Interviews conducted on 10/12/23 revealed the following: Interviews conducted with 3 out of 3 residents revealed residents are check often, at least every two hours. Residents do not smell due to the lack of incontinence care. Interviews conducted with 3 out of 3 staff revealed residents that required assistance with incontinence are check every two hours and change as needed. One resident is changed regardless the resident is soil or not every two hours, per family request. Interviews conducted with 2 family representatives revealed facility assist with incontinence care and residents are always clean and free of odors when visiting. Facility keeps a monthly incontinence care log for the residents, staff notes initials and reason for changing upon assisting the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Linda Fan and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 28-AS-20230503164443

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 13, 2023

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...assistance and care as... This requirement is not met as evidence by: Based on document review and interviews conducted licensee did not ensure staff provided a two person assist for R1 which poses an immedicate risk to the health, safety, or personal rights to the persons in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Administrator will schedule and conduct an in-service training with all staff regarding proper transfer, and incident reporting and will submit schedule of training by POC due date 10/13/23 and copies of training log sign-in with duration of training and topic by 10/19/23. *An immediate Civil Penalty of $500.00 is being assess during this visit*

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 13, 2023

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities shall...:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on document review, and interviews licensee did not ensure to seek medical care in a timely manner for R1 which poses an immediate risk to the health, safety, or personal rights to the persons in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Administrator will schedule and conduct an in-service training with all staff regarding section 87468.1. and will submit schedule of training by POC due date 10/13/23 and copies of training log sign-in with duration of training and topic by 10/19/23.

Allegation investigated: Facility retained resident with a prohibited health condition Resident received a pressure injury while in care Staff did not notify authorized representative of residents change in condition

Licensing Program Analyst (LPA) Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegations and for the purpose of rendering the findings. LPA met with Staff #1 Kevin Qin who allowed entry into the facility and assisted with the visit. The investigation consisted of the following: On 4/6/2021, LPA Sicairos conducted a virtual tour of the facility with the assistance of the Administrator which included the common areas and a random sample of resident rooms. LPA did not observe any immediate health and/or safety concerns. LPA also interviewed the Administrator. LPA requested copies of resident & staff rosters and copies of Former Resident #1 (R1's) file including but not limited to Physician's Report, Wound Care Assessment, Home Health Information, and Resident Appraisal. On 6/22/2023, LPA Wong interviewed the administrator and Staff#1 (S1). On 03/15/23, LPA Wong referred the complaint to Community Care Licensing (CCL) Program Clinical Consultant (PCC) for a review of medical records that were obtained. (See LIC 9099C for continuation) Substantiated The investigation revealed of the following: Allegation#1 “Facility retained resident with a prohibited health condition.” R1 was admitted to the facility on 12/28/20 but due to R1’s declining health and began to receive home health services on 1/1/2021. R1 began receiving home health services due to R1’s advanced age, decline in mental health, increased weakness and decline in functional status and incontinence. Per review of medical records obtained and the following was determined: On 01/04/21, R1 developed pressure ulcers on both buttocks. On 1/7/21, it was determined that the pressure ulcers on the left and right buttocks were determined to be stage 2. By 02/01/21, R1 had a total of 4 pressure ulcers determined to be stage 3. It was reported the pressure ulcers worsened over time. Although home health contacted the wound doctor to provide evaluation and treatment for R1, the facility continued to retain the resident with a prohibited health condition and failed to submit an exception request to the Licensing Department. Allegation#2 “Resident received a pressure injury while in care” R1 was admitted to the facility on 12/28/20 and R1’s family doctor ordered a home health service for R1 due to R1 was bedridden, weakness, and limited mobility. R1 was also identified as high-risk requiring emergency care services and hospitalization due to advanced age, decline in health and incontinence with a high risk of breakdown. It is alleged that when R1 was admitted to the facility on 12/28/20, R1 had a red mark on their buttocks area. Facility staff was aware of this. On 1/7/21, R1 was reported to have two pressure ulcers which had developed on left and right buttocks which were determined to be stage two. On 1/28/21, its documented that R1 developed three pressure ulcers. By 2/1/21, R1 had a total of 4 pressure ulcers with two stage 2, one deep tissue injury and one stage 3 pressure ulcers. Additionally, the facility also did not update, develop, and implement a plan of care when home health identified R1 was at risk of developing pressure ulcers. Allegation #3 “Staff did not notify authorized representative of residents change in condition” R1 was admitted to the facility on 12/28/20 and family took R1 out from the facility on 3/29/21. It was reported that prior to R1 admitted into the facility, R1 did not wear diapers and was not in wheelchair. It is alleged that, R1's family members were not allowed to be visited R1 in person due to COVID and visitors were only able to communicate with the facility through phone calls. According to R1’s family member, the administrator never provided any updates regarding R1’s change in health condition including that R1 had developed pressure ulcers while residing at the facility. R1’s family members stated that they attempted to go to the facility to visit R1 however due to COVID, she was not allowed to see R1 at the facility. (See LIC 9099C for continuation) R1’s family member also tried calling the administrator many times for follow up on R1’s health condition, but the administrator never communicated any updates regarding R1’s pressure ulcers. R1’s family member indicated that she was unaware of R1’s pressure ulcers until R1's family member took R1 out from the facility on 3/29/21 and a hole was observed on R1’s sacrum. At that time, R1’s pressure ulcers were staged by a doctor to be stage 4. No one in the facility notified R1’s family that R1 had developed these wounds. Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date. Exit interview was conducted and a copy of this report was provided, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Allegation “Staff did not seek timely medical care for the resident” R1 was admitted to the facility on 12/28/20, and R1’s initial Needs and Service Plan indicated that R1 had smelly urine. Facility did consult with R1’s primary care physician who ordered the home health services for R1. Home health ordered physical therapy for evaluation of physician status and rehabilitation. On 2/1/21, R1 developed total of 4 pressure ulcers and reported the pressure ulcers had worsened. Home health ordered the wound doctor for R1 to provide wound evaluation and treatment as needed. Before R1’s family took R1 back home on 3/29/21, R1 was under the care of a wound doctor. Wound doctor follow up on R1’s pressure injuries every 7 days until the last visit on 3/24/21. Based on record review and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED, Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 28-AS-20210405152422

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Sep 29, 2023

87615 Prohibited Health Conditions (a) 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: (1) Stage 3 and 4 pressure injuries. The requirement was not met as evidenced by record review, R1 had a total of 4 pressure injuries and determined to be stage 3 and R1 was still retained in the facility which posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: The administrator will ensure person who required health services shall not be admitted or retained in a residential care facility. The administrator will submit a plan of correction to ensure facility is meeting the Title 22 regulation by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 5, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a)(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The requirement was not met as evidenced by record review, when R1 was admitted to facility and facility staff was aware of R1 had a red mark on buttock area and facility did not update and develop a plan of care which posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Oct 5, 2023

87466 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. The requirement was not met as evidenced by LPA's interviews and R1's family reported they never got any updated from facility about the resident's change of condition until the day the family took R1 out from facility.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

Allegation investigated: Staff prohibited resident from having visitors. Staff did not treat resident with dignity or respect. Staff did not keep the facility free from clutter. Staff retaliated against resident due complaints regarding resident care.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met Linda Fan (Administrator) and explained the reason for the visit. The investigation consisted of the following: LPA Mora obtained copies of the resident and staff rosters, interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 - Resident 7 (R1 - R7), and 4 residents' responsible parties, and toured the facility. The investigation revealed the following: regarding the allegation "staff prohibited resident from having visitors", it is alleged that on 2/20/2023, a family member of a resident made an appointment with the facility and showed up with home health nurse and were denied entry to the facility. Administrator and staff denied the allegation. They stated that per their copy of the police report this occured on 02/17/23 during dinner time and all staff were in the dining room serving the residents. (Continued to LIC 9099-C) Unsubstantiated The staff told the family member via phone to wait a bit until they were done so they can go open the outside gate for them. However, the family member call the police right away because they were not provided entry to the facility right away. The police report does show a 02/17/23 date and the police officer determined that the allegation of elder abuse was unfounded. Residents interviewed could not corroborate with the allegation. Residents' responsible parties interviewed could not corroborate with the allegation and stated they have never had any visitation issues with this facility. The investigation revealed the following: regarding the allegation "staff did not treat resident with dignity or respect", it is alleged that a resident is being discriminated against based on language dialect and receives unfair treatment. Administrator and staff denied the allegation. Residents interviewed could not corroborate the allegation. Residents' responsible parties interviewed could not corroborate with the allegation and stated that during their visits they have not observed staff mistreating or discriminating against residents. The investigation revealed the following: regarding the allegation "staff did not keep the facility free from clutter", it is alleged that there was clutter obstructing the stairwells. Administrator and staff denied the allegation. Staff 1 (S1) confirmed that pieces of furniture were placed there but it was not obstructing the stairway. They were replacing old furniture with new furniture. The old furniture was removed from that spot by end of the day. A picture was attached to this complaint and based on the picture the clutter is not obstructing the stairwell or hallway. It is in an isolated area near the stairway. It is unknown how long the clutter was there. Residents interviewed could not corroborate the allegation. Residents' responsible parties interviewed could not corroborate with the allegation and stated that during their visits they have not observed any clutter and the facility is clean. During today's visit, the LPA did not observed any clutter in the facility and facility was clean. The investigation revealed the following: regarding the allegation "staff retaliated against resident due complaints regarding resident care", it is alleged that a resident's November 2022 eviction notice and limitations on visitation are believed to be retaliatory actions from the facility. Administrator and staff denied the allegation and stated visitation rules applied equally to all visitors. Administrator stated there is no eviction notice issued in November 2022 and that it was a recommendation to the resident's family that the resident might need a higher level of care due to the resident's violent behavior towards staff and other residents. Review of resident's records the only eviction notice found was issued on 01/09/2023 due to non-payment and resident needing higher level of care. Residents interviewed could not corroborate the allegation. Residents' responsible parties interviewed could not corroborate with the allegation. (Continued to LIC 9099-C) Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Jul 6, 2023 · control 28-AS-20230627145047

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with caregiver Kevin Qin. Assistant administrator Anna Dong assisted with the visit and Administrator, Linda Fan , also arrived to assist the visit at around 11:00am. The purpose for the visit was explained. The facility is licensed for residents age range 60 and over. Approved for 29 non-ambulatory and 14 bedridden, Hospice Waiver for 10. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following 12 domains: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is still in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. Currently they have 6 hospice residents reside in the facility. The facility has the sufficient amount for liability insurance covering injury to residents and guests. 3. Physical Plant and Environmental Safety: The facility is a two story building, on the first floor, it includes: Reception area, common area (Read newspaper area and exercise area), Administrator office, Dining Area, Kitchen, linen supply room, cleaning supplies room, ten (10) residents bedrooms, laundry room, food storage room and two unisex public bathrooms. On the second floor, it includes seventeen (17) residents bedrooms, rest area (TV and computer room), public bathroom but currently used it as storage. The facility also has a large back patio area. The passageways, walkways and patios are free from obstructions. On today's annual, LPA inspected five (5) residents bedrooms which include Room#101, #126, #128, #206 and #227. (See LIC809C for continuation) Each resident room has their own bathroom. Room#101 and #206 has two beds, two drawers, chairs, required beddings and sufficient lighting and closet space. Room#126, #128 and #227 has one bed, one chair, one drawer, required bedding and sufficient closet space and lighting. The resident bathrooms are clean, sanitary and in an operable condition. All resident bathrooms have grab bar and non skid mat/floor. Each resident room and bathroom have the signal system and they are working properly. The hot water temperature in Room#101 and #206 were tested between 100.2 and 100.7 degrees F. 4. Staffing: There is sufficient staffing at the facility. Staff does not have CPR and First Aid training except the administrator. 5. Personnel Record and Training: The facility administrator is Linda Fan and her administrator certificate will be expired on 11/15/2023 and she has sufficient training hours in file. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The caregiver/direct care staff do not have required training hours including medication management and initial training. 6. Resident Records and Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights. For Resident#1 and #2 admission agreement and they are not using the Font size 12 and the admission agreement is double sized. 7. Resident Right-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted are between the reception area and entrance area. 8.Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9.Food Service: The facility has sufficient food supply for 2 days perishable and 7 days non-perishable food supply. The food are properly stored in the refrigerator. 10. Incidental Medical and Dental: The resident's medication is centrally stored and locked in the administrator office. LPA reviewed five (5) residents medication and they all seemed updated and accurate, which contained 30-day supply of medication. (See LIC 809C for continuation) 11.Disaster Preparedness: The facility has an updated Emergency Disaster Plan dated on 6/22/23 The facility staff does not have annual emergency and disaster training. The facility does have two appropriate alternate shelter locations. 12.Resident with Special Health Needs: Currently there's no resident under Home Health Services. Six (6) residents are on hospice. No resident is on postural support and no residents have prohibited health condition. Half and full bed rails for mobility assistance were observed in resident rooms. Individual Service Plans and Appraisals are on file. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Administrator Linda Fan. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jun 22, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Deficiencies visit due to observation made while investigating complaint control # 28-AS-20230503164443 visit. The purpose of the visit was explained to Administrator Linda Fan. During tour of facility LPA observed the following deficiencies: · 2 bottles of prescription for R1 and R2 were observed on water dispenser machine in dining room area. This area was accessible to 35 out of 35 residents in care. · Water temperature in 1st floor bathroom#1 was measured at 96.4 degrees F, which does not meet Title 22 regulations. · Water temperature in 1st floor bathroom#2 was measured at 98.6 degrees F, which does not meet Title 22 regulations. · 1st floor storage 3 was observed to accessible and contained various tools, half bag of construction material, can of paint, oxygen tank and other potentially dangerous tools. · LPA observed several “Blood Glucose Testing and Insulin Injection Records” and “Incontinence Logs” taped outside several residents’ doors. Deficiencies are being cited. See LIC 809-D. Exit interview was held and a copy of this report, 809-D and appeals rights was provided via email due to printer problems.the state’s words, verbatim · CDSS document, May 4, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(2) · Plan of correction due date: May 5, 2023

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: LPA observed 2 bottles of medication for R1 and R2 sitting on top of a water dispenser machine, in dinning area. Medications were accessible to 35 out of 35 residents in care.the state’s words, verbatim · CDSS document, May 4, 2023

Plan of correction: Licensee will secure all medications and keep medications centrally stored. Licensee will retrain staff on safeguarding of medications. Licensee will send proof of re-training to LPA by POC due date via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(e)(2) · Plan of correction due date: May 9, 2023

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: 1st Floor shared bathroom# 1 and #2 water temperature read at 98.6 degrees F in bathroom # and 96.4 degrees F in bathroom#1.the state’s words, verbatim · CDSS document, May 4, 2023

Plan of correction: Licensee will maintain water temperature between 105 - 120 degrees F. Licensee will develop a water log and record water temeratures every 24 hrs for the next 5 calendar days. Proof must be submitted to LPA via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(13)(c) · Plan of correction due date: May 5, 2023

Licensing 87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. (c) All information and records obtained from or regarding residents shall be confidential. This requirement is not met as evidenced by: At 2:29 pm LPA observed "Blood Glucose Testing and Insulin Injection Sheet" taped to the outside of R3 bedroom door and "Incontinence Log" taped to the outside of R4 bedroom door. LPA observed these logs on several residents doors throughout the facility.the state’s words, verbatim · CDSS document, May 4, 2023

Plan of correction: Licensee will remove logs regarding care of resident immediately from resident doors. Licensee shall maintain these logs in a secure location and keep information confidential.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: May 5, 2023

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). During tour, LPA observed storage door 3 to be unlocked and contained various tools, paint, oxygen tank and other potiential dangerous tools.the state’s words, verbatim · CDSS document, May 4, 2023

Plan of correction: Licensee will keep storage 3 and all storage doors inaccessible to dementia residents.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with 2 staff Staff 1 (S1) and Staff 2 (S2). S1 was determined to not have a criminal record clearance. Shortly after Administrator Linda Fan arrived. The reason for the visit was explained. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. The facility cares for elderly residents and is allowed to have 10 hospice residents. There are currently 3 residents on hospice. LPA and Administrator toured the facility which included a random sample of resident rooms along with the kitchen, dining room, linen room, upstairs and downstairs lobbies, laundry room and medication room. The backyard patio area is well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the patio area. Passageways and exits are free of obstruction. The common areas are clean and have the required furniture. There is a screening station at the entrance of the facility which has PPEs and a thermometer to screen visitors. Staff document resident temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs. The resident bathrooms have the required grabs bars and non-skid mat. The water temperature was tested in a random selection of resident bathrooms. Hot water temperature measured at 122.2 degree F in bathroom #201 and in share bathroom for the rooms #202 and # 203. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Continue 809C. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is several carbon monoxide detectors throughout the hallways of the facility. There are several fire extinguisher located throughout the facility. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Cleaning supplies and toxins were observed in the laundry room unlocked and accessible to residents. LPA reviewed 3 resident records to confirm emergency contact is updated, physician's reports are on file, and admission agreements are complete. Two staff records were reviewed to confirm health screenings, training and fingerprint clearances. LPA reviewed 3 residents' medications. Medications are documented properly and given as prescribed. First Aid kit was fully stocked with current manual. Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to Administrator.the state’s words, verbatim · CDSS document, Jun 15, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Linda Fan and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected. The following were observed/inspected: LPA and Administrator toured the facility which included a random sample of resident rooms along with the kitchen, dining room, linen room, upstair and downstai lobbies, and medication room. The backyard patio area is well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the patio area. Passageways and exits are free of obstruction. The water temperature was tested in a random selection of resident bathrooms and measured at 119.1F. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is several carbon monoxide detectors throughout the hallways of the facility. There are several fire extinguisher located throughout the facility. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Cleaning supplies and toxins are locked in a storage room and are inaccessible to residents. First Aid kit was fully stocked with current manual. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. A random sample of medications were reviewed. LPA observed Administrator did not have a current record of centrally stored prescription medications for each resident. Administrator indicated Medication Administration Record Sheets (MARS) for residents were not up to date, however she was currently working on them. Staff and Resident files were not reviewed during today's visit. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 29, 2021