Henrietta's Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) N. Galarza arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation. LPA was greeted and granted entry by caregiver staff. Administrator Belen Taico was explained the purpose of the visit telephonically. The following was observed during the inspection: Infection Control: The facility has an Infection Control Plan that is reviewed annually. Operational Requirements: A Dementia and hospice waiver for 4 residents has been approved. A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 4. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate expires 8/26/2026. Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The facility is located in a residential neighborhood that consists of 4 resident rooms, 2 bathrooms, dining room/ living room, office, laundry room, medication/storage room, outdoor patio area, and detached garage. Smoke and carbon monoxide detectors were tested and are operational. The facility has three (3) fire extinguishers. Rooms are equipped with required furniture and bedding. Cleaning supplies and toxic substances are inaccessible to residents. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Electrical smoke and carbon monoxide detectors were tested and are operational. The facility maintains emergency food supply and water. Emergency Phone numbers, exit plan and programming schedules were posted. The building contains central air conditioning and heating. First aid kits/Manuals are kept in activity rooms; consisting of thermometer, tweezers, scissors, antiseptic, bandages, gauze. Exit doors are free of any obstruction. The last Emergency Disaster drill was conducted on 6/18/2026. * R1 & R2's bed had full length bed rails but residents are not enrolled in hospice. Room #4 has an oxygen tank, but required No Smoking posting was not observed. Staffing: A total 6 staff members provide care and supervision to the residents. Personnel Records/Staff Training: Five files were reviewed. Files were reviewed for criminal background clearance, training, health clearance, and 1st Aid/CPR training. Staff (S4) is not associated to the facility. Staff S3 & S4 do not have health screening. Staff (S3) does not have a 1st Aid/CPR training. Administrator did not provide documentation during the visit. Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. RCFE complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. One resident has a modified diet. Incident Medical and Dental: Centrally stored / 30-Day supply of medications were reviewed. Medical and dental transportation is provided by family. Resident (R1's) Centrally Stored Medication And Destruction Record is not current. Four medications were not listed. *NOTE: The facility does not use MAR's. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. Residents with Special Health Needs: Zero residents are enrolled hospice services and three (3) residents receive home health services. Pursuant to Title 22, deficiencies were cited. An exit interview was conducted with Crystal Garcia. A copy of the report/appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 25, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to caregiver Andres Hernandez. The facility serves elderly residents ages 60 and older. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed and includes environmental cleaning and disinfection activities. Facility has sufficient Personal Protective Equipment. Operational Requirements: A Dementia and hospice waiver for 4 residents has been approved. The facility has a fire clearance for 6 non-ambulatory residents. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current and expires 8/26/2025. Physical Plant/Environment Safety: The facility is located in a residential neighborhood that consists of 4 resident rooms, 2 bathrooms, dining room/ living room, office, laundry room, medication/storage room, outdoor patio area, and detached garage. Smoke and carbon monoxide detectors were tested and are operational. The facility has three (3) fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual. The last Emergency Disaster drill was conducted on 5/30/2025. Cleaning supplies and knives were locked. Exit doors are free of any obstruction and there are no pools or large bodies of water. Medication pills in dispensing cups were observed in an unlocked kitchen drawer. Alcohol/alcoholic drinks were observed unlocked in the bottom kitchen cabinet which pose a safety risk to Dementia residents. Staffing: A total 8 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 11/14/2025 Assistant Administrator's certificate expires 3/10/2026. Staff have criminal background clearance and training. Six (6) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training is current. Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. RCFE and Ombudsman complaint posters are posted in the dining area. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Two residents have modified diets. Incident Medical and Dental: Centrally Stored Medication records and medication inventory was reviewed. 30-day supply of medications was observed. Medical and dental transportation is provided by family. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. Residents with Special Health Needs: Three (3) resident receive hospice services and one (1) resident receives home health services. Three (3) residents have Dementia. No residents have prohibited health conditions. Half and full bed rails for mobility assistance physician orders are in place. Per Title 22, deficiencies were observed. Refer to LIC 809D. An exit interview was conducted with caregiver Andres Hernandez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 24, 2025

Allegation investigated: Staff did not provide safe and competent assistance with postural support of terminally ill resident.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit Lead Caregiver Andres Hernandez. House Manager Belen Taico arrived shortly after. The investigation consisted of: A physical plant tour of the facility and record review was completed. Staff (S1-S4) were interviewed. No residents were interviewed due to cognitive impairment. Resident (R1) passed away and was not interviewed. The following documents were reviewed/obtained: Resident (R1's) Face Sheet, Death Report, Preplacement Appraisal, Resident Appraisal, Valley Hospice Orders, Physician's Report, Plan of Operation, resident roster, and LIC 500 Personnel Report. Substantiated Allegation: Staff did not provide safe and competent assistance with postural support of terminally ill resident. It is alleged that on June 3, 2024 at 6:09 AM Dementia resident (R1) was found laying in the hospital bed in an unusual manner. The lower part of the bed foot area was propped higher with a laundry basket. According to report night shift staff (S1) was on duty and is suspected to be the caregiver staff who placed the basket in order to prevent the hospice resident from getting up often during nighttime. According to information obtained, the incident was reported to House Manager, but no action was taken to ensure resident's safety. The resident was receiving hospice services and passed away August 11, 2024. A total of 4 staff were interviewed, of which all denied the allegation. Three (3) staff saw the 3 pictures obtained by Community Care Licensing and acknowledged staff negligence. The staff in question staff (S1) denied the allegation, and stated that a former staff (S5) was likely the caregiver that placed the laundry basket under R1's mattress. House Manager stated that former staff (S5) complained that R1's was difficult to care for and often got up at night. Manager stated that S5 said that pillows and bed rail pads were used to concave R1 in the bed in order to keep the resident in bed. House Manager stated there was disciplinary action against former staff (S5), but the caregiver refused to sign the document. There is sufficient evidence to corroborate the allegation. Based on interviews conducted, record review, and photographic evidence the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited in LIC 9099D. An exit interview was conducted and a copy of this report and appeal rights was provided to House Manager Belen Taico. Allegation: Staff are interfering with daily functions by putting residents to bed early. It is alleged that caregiver staff are putting to bed residents too early, at approximately 5:30 PM after dinner time because only one (1) caregiver staff works the night shift staff. According to information obtained, staff are doing this in order to facilitate the night shift caregiver responsibilities. Day shift begins at 7 AM and ends at 7 PM. The night shift staff work from 7 PM - 7 AM. The complaint alleges day shift staff are instructed to get the resident ready for bed after they eat dinner and before the night shift staff begins their shift. Based on interviews conducted a total of 2 caregivers work the day shift. A total of 4 staff were interviewed. One (1) out of the 4 staff stated the residents are taken to their rooms at approximately 6 PM, before the night shift staff starts their shift. Other staff stated that if the residents are placed in bed early it is out of choice. House Manager stated that former resident (R1) liked to go to bed early because they awakened early. Per Plan of Operation, residents are supposed to be prepared for bed at 8:00 PM, and residents may go to sleep at 9:00 PM, or earlier if desired. Due to Dementia diagnosis residents are cognitively impaired and were not interviewed. There is insufficient evidence to corroborate the 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. Exit interview conducted with House Manager Belen Taico. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 10, 2025 · control 28-AS-20250103101146

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5) · Plan of correction due date: Jan 11, 2025

Postural Supports. Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.” Based on photographic evidence night shift caregiver placed a laundry basket under R1's hospital bed mattress in order to limit the resident from getting up at night. Pillows and rail pads were also used. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2025

Plan of correction: Administrator shall submit a written plan of correction by tommorrow. Submit staff in-service training by Tue. Jan. 14, 2025.

Allegation investigated: Staff mishandled the residents medications. Staff did not provide adequate care and supervision to a resident. Staff did not properly report an incident involving the residents.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate and deliver findings on the above allegations. The purpose of the visit was discussed with Facility Manager Belen Taico. The investigation consisted of: On 7/25/2024, a physical plant tour of the facility was completed. Relevant documents pertaining to the allegations listed above were requested but not provided until the following day. Documents provided included information on residents (R1-R6). On 12/11/2024, staff (S1-S6) and residents (R5- R6) were interviewed. During the course of the investigation, 3 responsible parties, 1 home health staff, and 3 hospice agency staff were interviewed. During today's visit, staff (S3-S5) were interviewed regarding photographic evidence obtained. *See next page for narrative. Substantiated Allegation: Staff mishandled the residents' medications. It is alleged that night shift staff (S1) placed resident (R1's) PRN Lorazepam bubble pack in their backpack. According to information obtained, the Lorazepam's physician order was effective January 2024- June 2024. When R1's family was moving out the resident it was discovered that the PRN bubble pack medication could not be found. House Manager was informed the medication was missing. Manager allegedly had R1's PRN medication on top of their office desk, and stated that the medication had just been received. It is unknown why another bubble pack was ordered if R1 had only been administered 3 PRN pills during January 2024- June 2024. Two (2) out of 8 staff interviewed stated they saw a medication bubble pack that resembled the resident(s) bubble packs in staff (S1's) backpack. Facility Manager was notified of incident. Staff (S1) denied the allegation and stated that when R1 lived at the facility no other residents required night PRN medications. Staff interviewed stated that medications are counted every morning and are to be locked and centrally stored. Out of the six staff that denied the allegation, two staff stated they are not responsible for counting medications and cannot be sure if S1 took R1's medication and placed it inside their backpack. Staff were shown a picture of the alleged backpack that showed a bubble pack sticking out of the bag. Staff stated they do not know which staff the backpack belonged to, but acknowledged that the medication bubble pack should not have been readily accessible to residents in care. Staff were shown the photo depicting an unlocked medication bubble pack. Based on record review and photographic evidence there is sufficient evidence to corroborate the allegation because medications shall be kept 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. Allegation: Staff did not provide adequate care and supervision to a resident. It is alleged that staff showed negligence in caring for resident (R1) because the resident fell twice out of their chair while sitting in the dining room table. Additionally, it was reported that another resident (R4) was hospitalized in May 2024 due to a fall incident. Based on five (5) out of eight (8) staff interviews, the findings indicate that resident (R1) did fall while sitting in the dining room chair, and resident (R4) also sustained 2 falls, one was while sitting on the dining room chair, and the other was in their room where she sustained a large cut on the forearm. According to staff interviews, when resident (R1) fell in the dining area there were staff in the living room area next to the dining area, and R4's fall in their bedroom was not witnessed. Staff protocol is to check on residents every 1-2 hours when they are in their bedrooms and maintain constant supervision when they are in the living and dining room area. Based on record review, the facility did not submit to DSS Community Care Licensing fall incident reports pertaining to R1 & R4's falls. There is sufficient evidence to support the allegation. Allegation: Staff did not properly report an incident involving the residents. It is alleged that facility Administration staff did not notify residents responsible parties and Public Health about suspected scabies cases in the home. Resident (R1) and other residents received prophylaxis treatment for scabies. Facility manager stated that there was a resident that had a chronic skin disease that looked like scabies, but a biopsy did not confirm scabies. Facility Manager confirmed the suspected cases were not reported to public health or CCLD. All responsible parties interviewed stated they had no knowledge nor were notified that their loved ones were treated for suspected scabies. Per staff interviews, hospice agency staff recommended all residents be treated with Permethrin cream. All staff interviewed confirmed that residents received prophylaxis Permethrin treatment because they did not know if the rashes observed were scabies. Based on record review, the facility did not communicate to responsible parties the reason for the prophylaxis Permethrin treatment. A home health staff stated they developed a rash and were also treated for scabies. Resident (R1) fell twice while sitting in the dining chair, and resident (R4) fell twice, once while in their room, and in May 2024 while sitting in the dining room chair. The aforementioned fall incidents were not reported to CCLD. Additionally, no incident reports were submitted to DSS Community Care Licensing as required. Therefore, there is sufficient evidence to support the allegation that facility failed to properly report the suspected scabies cases. Based on interviews conducted, record review, and photographic evidence the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited in LIC 9099D. An exit interview was conducted and a copy of this report and appeal rights was provided to Facility Manager Belen Taico. Allegation: Staff physically abused a resident. The report states that on December 6, 2023, staff (S1) left bruising on Dementia resident (R1’s) both arms and left wrist that showed fingerprints. It is alleged that House Manager told family that former staff (S9) was the suspected perpetrator in effort to cover up for night shift staff (S1). A total of 8 staff were interviewed, of which 6 out 8 staff denied the allegation. Staff (S1) denied the allegation and stated one time they observed bruising on R1’s wrist, and staff it was likely due to mishandling of resident by other shift staff. Staff interviews revealed that R1 bruised easily due to very thin skin and combative illness behavior that included kicking, pulling of hair, and banging on full bed rails. Two (2) resident representatives of other residents residing in the home, and home health aide were interviewed, none reported observation or knowledge of alleged physical abuse. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: Resident sustained unexplained injuries while in care. It was reported that on 8 dates [Dec. 6, 2023, Jan. 24, 2024, Feb. 14, 2024, Mar. 27, 2024, May 22, 2024, Jun. 20, 2024, and Jun. 26, 2024] Dementia resident (R1) had bruises on legs/thighs and arms, cuts and scrapes on knees, wrist area bruising, a sore on left leg, and bruise on right shoulder/arm area. It is alleged night shift caregiver (S1) caused the injuries because the staff works alone during the night shift and is known to be inpatient and abrasive in handling the residents. It was also reported that a now deceased resident (R2) was observed with scratches on their face, and the cognitively impaired resident stated that “the lady at night” scratched and hit the resident. Based on eight (8) staff interviews, none of the staff reported observing any staff mishandling the residents. Staff stated that due to cognitive impairment some of the residents often get combative during incontinence changes and feeding time. Staff stated that R1 often hit themselves on the bed rail or in the dining room table when the resident experienced aggression and anxiety. Staff stated they try to calm residents by giving them time and addressing the behavior incident a little later. None of the 3rd party persons interviewed had knowledge of allegation. Record review revealed that R1 has physician orders for 2 antipsychotic medications that are used to manage behavioral symptoms like agitation and aggression in dementia residents. Therefore, there is insufficient evidence to support the allegation. Allegation: Staff verbally abused the residents. It is alleged that staff (S1) was overheard cussing at resident (R2) and on a different date the staff person was heard telling R2 “don’t be a pig when the resident was eating at the dining table. According to information obtained, S1 addressed R2 & R3 in a demeaning manner by saying that the residents are pigs and gross, and by yelling at resident (R4) when the resident requested more cookies. It was reported that night shift staff were verbally abusive because they treated residents R2 & R4 in a mean way. Resident (R1) referred to staff (S1) as “bad”. Based on 8 staff interviews, 2 out of 8 staff confirmed the allegation by stating that night shift caregiver staff (S1) is known to treat the residents impatiently and in a demeaning manner. Staff (S1) denied the allegation and stated they do not yell at residents. Other staff denied the allegation and stated that all staff treat the residents with respect. Responsible parties and 3rd party agencies had no knowledge of verbal abuse or mistreatment. Two (2) residents with limited verbal ability were interviewed. One (1) resident reported no verbal abuse, and the other resident stated that night shift S1 is “half nice and half not nice”. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: Staff did not meet a resident's diabetic needs. It is alleged that Facility Manager did not order necessary blood sugar strips to check resident (R1’s) sugar levels, and as a result staff did not check the resident’s blood sugar levels for approximately 5 days. Resident (R1) wore a diabetic sensor on their arm, and there is always supposed to be back-up glucose strips for the glucose meter in case the diabetic sensor is removed from the arm. The complaint alleges that on June 2, 2024, it was discovered that R1 had been without glucose testing strips since the last week of May 2024. A total of 8 staff were interviewed, of which 2 reported that the facility had insulin medication, but did not have glucose strips that measure sugar levels. According to staff interviews, R1 often pulled off the sensor monitor and/or it fell off, and the facility did not have another arm monitor. Therefore, protocol was to prick R1's finger and measure the glucose level on the glucose strip. The arm sensor is to be replaced approximately once a month. Six (6) out of 8 staff denied the allegation by stating that the facility did have glucose strips, but R1's family requested staff use a different brand type to be used. Staff interviews revealed that the facility did have diabetic lancet strips that were smaller in size because the house glucose monitor is smaller in size. According to staff interviews, R1's family thought that the house supply of strips were not reading the sugar levels correctly. House Manager stated they had no knowledge of any caregiver staff purchasing glucose strips in order to measure R1's glucose level. None of the 3rd party persons interviewed had knowledge of allegation. There is insufficient evidence to support the allegation. Allegation: Staff did not meet a resident's incontinence needs. It is alleged that in December 2023, a nighttime caregiver (S10) did not provide incontinence changes to residents in care and when a visitor entered the home it smelled like urine and feces. As a result, two other staff had to bathe the residents that morning, and threw away comforters, sheets, and bedding because they were heavily soiled. It is alleged that S10 stopped working at the facility and then in May 2024 was hired back, but the staff failed to provide incontinence care again and they were fired the following day. Based on staff interviews, it was stated that staff are supposed to check on residents every 2-3 hours and change their diapers as needed. Staff stated that during daytime hours they are checked frequently and changed right away, and during nighttime they are supposed to be checked at 9:30 PM, 12:00 AM, 3:00 AM, 5:00 AM, and then they are awakened at 6:30 AM and changed again if needed. Staff stated that sometimes the residents refuse incontinence assistance, but staff make further attempts, and they get changed. All staff denied the allegation. Responsible parties interviewed had no knowledge of incontinence care negligence. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not prevent the residents from obtaining scabies while in care. It is alleged that multiple residents were treated for scabies between December 2023 – through mid-June 2024, but House Manager told caregivers that residents had eczema, and all residents were being bathe and provided incontinence care in one bathroom, despite the facility having another bathroom. As a result, resident (R1) contracted scabies. Based on record review and staff and hospice agency staff interviews the findings indicate that there were multiple residents experiencing skin conditions i.e. dry skin, general itchiness, and rashes on bilateral extremities, and as a precaution hospice agency staff ordered prophylaxis Permethrin treatment for all the residents. Based on hospice agency interviews, the findings indicate that the rashes the residents had did not improve with the Permethrin treatment. They improved with Benadryl lotion and pill, which indicates that it was most likely an allergic reaction. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not isolate residents with scabies. According to information obtained staff did not isolate any of the residents that were suspected to have scabies between December 2023- June 2024, because the residents were still being allowed to congregate together in the living room and dining room areas where they spend most of their day in. A total of 8 staff were interviewed, of which 7 stated they had no knowledge of confirmed scabies cases, but if there are residents with confirmed scabies, they are to be isolated and their medical providers and/or hospice nurses would be notified. One (1) staff reported that House Manager did not isolate the residents even when they were being treated for suspected scabies because they wanted all the residents in the living room area to better supervise them. Facility staff provided written documentation from hospice agencies, and hospice staff were interviewed regarding suspected scabies cases. None of the hospice agency staff stated there were confirmed cases. They stated that as a precautionary measure all the residents showing rash like symptoms received prophylaxis Permethrin cream treatment. Staff confirmed that the residents received the treatment as recommended per medical professionals. None of the staff interviewed reported having had confirmed scabies. Therefore, there is insufficient evidence to prove the allegation. 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 conducted with Facility Manager Belen Taico. A copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 18, 2024 · control 28-AS-20240722124008

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Dec 19, 2024

Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: 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 was not met evidenced by: Based on photographic evidence the findings indicate that a staff backpack that was placed on top of the kitchen counter by the toaster oven had a medication bubble pack sticking out, it is unknown which resident the medication belonged to, but medications must be locked. This poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2024

Plan of correction: Licensee shall ensure all medications are locked and centrally stored, controlled subtance medications are accounted for, and MAR records are accurate. Submit by tomorrow a written POC, and proof of staff training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Dec 24, 2024

Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met evidenced by: Resident (R1) fell twice while sitting in the dining room chair, R4 had 2 falls; 1 in their room and iin May 2024 while sitting in the dining room chair, and as a result was hospitalized due to injuries. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2024

Plan of correction: Administrator shall ensure that all residents in care are provided with adequate care and supervision to ensure their safety. Submit: 1. A plan on how the Dementia residents' safety will be ensured while sitting. 2. Proof of staff training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Dec 24, 2024

Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: cA 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 ... date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met evidenced by: Between Dec. 2023- June 2024 there were suspected scabies cases, that resulted in prophylaxis Permethrin treatment of residents, but none of the responsible parties had knowledge of treatment and CCLD did not receive any incident reports. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 18, 2024

Plan of correction: Administrator shall ensure all incidents involving residents are reported to CCLD via fax and responsible parties. Submit written statement and proof of staff training.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to Assistant Administrator Belen Taico. The facility serves elderly residents ages 60 and older. A hospice and Dementia waiver is in place. The facility is located in a residential neighborhood that consists of 4 resident rooms, 2 bathrooms, dining room/ living room, office, laundry room, medication/storage room, outdoor patio area, and detached garage. The inspection was completed using the CARE tools. Twelve (12) CARE tools domains were reviewed. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs). Operational Requirements: A hospice waiver for 4 residents is in place. A fire clearance for (6) non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 4 only. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 8/26/2024. Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. The facility has (3) fully charged fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Facility has a fire pull-alarm in the dining area. Staffing: A total of 5 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 11/14/2025. Staff have criminal background clearance and training. Five (5) staff files were reviewed. Proof of staff training, health and TB clearance, and 1st Aid/CPR training are on file. Resident Records/Incident Reports: A total of three (3) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records are in place. Facility does not utilize Medication Administration Records. RCFE complaint poster and Personal rights were observed posted. However, the RCFE Poster is 8 x 10, instead of 20 x 26 inches. A technical advisory was issued. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. One resident has a modified diet plan. Incident Medical and Dental: Six (6) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 6/21/2024. Residents with Special Health Needs: Three (3) residents are receiving hospice services and zero (0) resident receive home health services. All 3 residents have a Dementia diagnosis. Full bed rails for mobility assistance were observed in hospice resident's rooms. No residents have prohibited health conditions. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Assistant Administrator Belen Taico. A copy of the report and appeal rights was issued.the state’s words, verbatim · CDSS document, Aug 20, 2024

Allegation investigated: Facility illegally evicted a resident in care.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit in regards to the allegation listed above. LPA discussed the purpose of the visit with House Manager Belen Taico and with telephonically with Administrator Robin Aquino. The investigation consisted of: A physical plant tour of the facility, record review, Hospital case worker and staff (S1-S4) were interviewed. No residents were interviewed due to cognitive impairment due to Dementia. The following documents were reviewed/obtained: Identification and Emergency Information/Face Sheet, Admission Record, Preplacement Appraisal Information, Resident Appraisal, incident report, Cal Aim Appraisal, Physician's Report, LIC 500 Personnel Report, and resident roster. ***See narrative summary on next page.*** Unsubstantiated Allegation: Facility illegally evicted a resident in care. According to information obtained, the facility moved resident (R1) to a skilled nursing facility (SNF) for an evaluation without responsible party's permission, and the responsible party was under the impression that the resident would be returning to the facility. Based on interviews conducted, Administrator and House Manager stated that resident (R1) often complained of pain and requested to be evaluated by a doctor. Staff stated that R1's responsible party was informed and agreed to the reason for the transfer to the hospital. On January 17, 2024, R1 was transported to Southern California Hospital for an evaluation because of lower extremities and low back pain. According to staff interviews, the hospital MD ordered the resident be transferred to a skilled nursing facility (SNF) because R1 required a higher level of care. The hospital case worker notified House Manager that R1 was not returning to the facility. LPA spoke to Southern California Hospital case worker and it was confirmed that R1 was transferred to a SNF per physician's order. 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. Exit interview conducted with House Manager Belen Taico. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 28-AS-20240226121018