Maison De Fleurs

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Ralph Estanislao, Administrator Assistant. LPA explained the purpose of the visit. The facility has a capacity of six (6) to serve residents from age 60 and above which may have six (6) non-ambulatory and three (3) hospice waivers. Three (3) residents are on hospice. Administrator certificate is current and expiration date is 03/17/25. Annual fees are current. During the visit, the CARE tool was used, facility tour was conducted, food supply was reviewed, staff/residents records were reviewed and medications were reviewed. The facility is a single story house located in a residential neighborhood in Covina consisted of three (3) bedrooms, two (2) bathrooms, open living room, dining room next to the kitchen, laundry room, outdoor patio and a storage shed in the backyard. Residents' bedrooms have dresser, chair and closet space available. Bathrooms, kitchen, common areas were inspected and in compliance. Two (2) days perishable and seven (7) days non-perishable were observed. Hot water temperature was in a range of 115.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Dual combo of smoke and carbon monoxide detectors are operable. Fire extinguishers are fully charged. Auditory devices are operable. Medication is centrally stored. Resident records are stored in a locked storage room and inaccessible to residents. No deficiency is cited per California Code of Regulations, Title 22. An exit interview was conducted and this report was provided to Administrator assistant, Ralph.the state’s words, verbatim · CDSS document, Oct 23, 2023

Allegation investigated: Resident sustained an unexplained injury while in care

Licensing Program Analyst (LPA) Angelica Rea conducted a subsequent complaint visit in response to the allegation(s) listed above. LPA met with Biblia Ong and explained the reason for the visit. Regarding the allegation of lack of supervision, specifically that resident #1 sustained an unexplained injury while in care. The investigation was conducted by the department, and consisted of interviews with staff, residents, and review of resident #1 medical records. The investigation revealed that resident #1 experienced a fall at the facility on 8/8/21. Staff was present when resident #1 fell. Staff stated that resident #1 did not express pain, and was only observed to have a small scrape on the side of his head. Staff stated that resident #1 was assessed by facility staff, but was not assessed by a medical professional. On 8/15/21, resident #1's family member observed that resident #1 was unable to stand. Resident #1's family member asked staff if anything had happened to resident #1, and staff disclosed that resident #1 had fallen from his wheelchair on 8/8/21. Resident #1's family member took resident #1 to hospital on 8/15/21, and resident #1 was diagnosed with a hip fracture. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Unsubstantiated The investigation revealed that although resident #1 sustained an injury, it was not due to lack of supervision. 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.the state’s words, verbatim · CDSS document, Aug 11, 2023 · control 28-AS-20210816151435

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Aug 18, 2023

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by: facility staff failed to report that resident #1 to community care licensing, and failed to report to resident #1's family member.the state’s words, verbatim · CDSS document, Aug 11, 2023

Plan of correction: Administrator will conduct and in service training with facilty staff regarding reporting requirements. Administrator will provide proof of training to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(6) · Plan of correction due date: Aug 18, 2023

Basic services shall at a minimum include: Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by : facility staff did not ensure that resident #1 was assessed by a medical professional after falling on 8/8/21.the state’s words, verbatim · CDSS document, Aug 11, 2023

Plan of correction: Administrator will conduct an in service training with facility staff regarding meeting the basic services of the residents. Administrator will provide proof of training to LPA by POC due date.

Allegation investigated: Staff did not provide authorized representative with resident's records

Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegation listed above. LPA met with staff#1at the facility, spoke with administrator assistant and licensee over the phone during the visit. LPA explained the purpose of today's visit to them. The investigation consisted of the following: LPA interviewed staff from staff#1 to staff#3 and reviewed records. LPA obtained copies of resident roster, staff roster, document request, dated 05/18/23 (Electronic mail) with a Power of attorney. In regard to allegation "staff did not provide authorized representative with resident's records," it was alleged that facility did not provide the requested document to resident#1’s attorney on a timely basis. LPA interviewed Administrator and staff. Staff interviews revealed resident#1 was a former resident residing at the facility from Aug 2021 to Sept 2021. (-continued in LIC 9099 C-) Substantiated Per facility record reviews, an authorization/ power of attorney was provided to licensee along with the record request dated 05/18/23. Licensee had not provided the requested documents to authorized representative as of today, 06/01/23. Therefore, facility failed to provide resident’s records to the authorized representative within two (2) business day. Based on LPA's observations, record reviews and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D. An exit interview was conducted with staff#1. A hard copy of this report and appeal right were provided.the state’s words, verbatim · CDSS document, Jun 1, 2023 · control 28-AS-20230531145412

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jun 5, 2023

(19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement was not met by evidence of: Per interviews conducted and record reviews, Licensee failed to provide resident#1’s records to resident#1’s authorized representative upon written request on 05/18/23, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 1, 2023

Plan of correction: Licensee agreed to provide the requested resident records to authorized representative by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Ralph Estanislao, Administrator Assistant. LPA explained the purpose of the visit. The facility has a capacity of six (6) to serve residents from age 60 and above which may have six (6) non-ambulatory and three (3) hospice waivers. Two (2) residents are on hospice. Administrator certificate is current and expiration date is 3/22/2024. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is a single story house located in a residential neighborhood in Covina consisted of three (3) bedrooms, two (2) bathrooms, open living room, dining room next to the kitchen, laundry room, outdoor patio and a storage shed in the backyard. Residents' bedrooms have dresser, chair and closet space available. Adequate linen and personal hygiene supply are observed. Adequate linen and personal hygiene supplies. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. The kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. Stove tops are in working condition. Hot water temperature was in a range of 114.3 degrees Fahrenheit which was within Title 22 Regulation guidelines. Facility maintains a comfortable temperature of 72.4 degrees Fahrenheit for residents. (-continued in LIC 809 C-) Dual combo of smoke and carbon monoxide detectors are operable. Fire extinguishers are fully charged. Auditory devices are operable. The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored. Resident records are stored in a locked storage room and inaccessible to residents. No deficiency is cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to facility Administrator assistant, whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Oct 7, 2022

Allegation investigated: . Smoking is occurring inside of the facility. 2. Resident’s care needs are not being met. 3. Residents are forced to go to bed at an unreasonable hour.

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced investigation for the allegations listed above. LPA met with Caregiver staff and explained the purpose of the visit. The investigation consisted of the following: LPA Chan obtained a copy of the Resident roster, toured the facility, and interviewed the Co-Administrator, 2 Staff, and 3 Residents’ family members/friend. LPA attempted to interview the 4 Residents but were not successful. Residents were either sleeping or could not answer questions. Another resident is in the hospital and was not interviewed. LPA also reviewed 3 Residents’ files. (Continue on LIC9099C) Unsubstantiated The investigation revealed the following: Allegation – Smoking is occurring inside of the facility. It is alleged that staff are smoking in the facility with residents that use oxygen. LPA toured the facility and observed 1 resident using oxygen. There was a sign posted at the front door stating, “No Smoking: Oxygen in Use”. According to interviews with Staff, they do not smoke and understand the danger of smoking while oxygen is in use. Per Co-Administrator, staff never smoke in the facility and if they want to smoke, they may do so outside of the facility in the patio area. LPA interviewed 3 Resident’s family members or friend, and all stated there are no cigarette smell or odor nor seen any staff smoking when visiting. Allegation – Resident’s care needs are not being met. It is alleged that staff are not responsive. The Co-Administrator and Staff interviewed stated they take care of their residents and tend to their needs daily. Staff stated they observe for resident’s behaviors and assist immediately. They check on residents often during the day and at night and change their diapers, feed them, shower them, and administer medications. According to family members interviewed, staff are doing a good job in caring for the residents and are attentive. Allegation - Residents are forced to go to bed at an unreasonable hour. It is alleged that residents need to go to bed at 5pm. Based on interviews with the Co-Administrator and Staff, residents are not forced to go to bed at 5pm. Dinner is served at 4:30pm and after dinner, residents have a choice to go their rooms or stay in the living room. Some will ask to go to their bedrooms, while some stay outside. Residents’ family members and friend interviewed stated that they visit at different times, sometimes in the evenings, and did not see staff forcing residents to sleep. 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. An exit interview was conducted with Staff. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 22, 2021 · control 28-AS-20211214124825

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Ralph Estanislao, Administrator Assistant, and Alicia Tongol, Staff. LPA explained the purpose of the visit. The facility has a capacity of six (6) to serve residents from age 60 and above which may have six (6) non-ambulatory and three (3) hospice waivers. Current resident census is four (4). Two (2) residents are on hospice. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. This home is a single story house located in a residential neighborhood in Covina. The facility consisted of vaulted ceilings with three (3) bedrooms, two (2) bathrooms, open living room, dining room next to the kitchen, laundry room, outdoor patio and a storage shed in the backyard. No garage. The kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. Stove tops are in working condition. Residents' bedrooms have dresser, chair and closet space available. Adequate linen and personal hygiene supply are observed. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 118.2 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. (-continued in LIC 809 C-) Dual combo of smoke and carbon monoxide detectors are operable. Fire extinguishers are fully charged. Auditory devices are operable. The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored. Resident records are stored in a locked storage room and inaccessible to residents. There are no pools and bodies of water on the premises. There are no firearms on the premises. Facility maintains a comfortable temperature of 73 degrees Fahrenheit for residents. Deficiency is cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to facility Administrator assistant, whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Oct 20, 2021