Cedar Creek Senior Living

Allegation investigated: Staff did not make all licensing reports issued by CCL accessible to residents

On 10/9/2023 Licensing Program Analyst B. Miranda arrived at the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Kimberly Jones was contacted and met with LPA. 1. The Department investigated the allegation: Staff did not make all licensing reports issued by CCL accessible to residents. LPA interviewed staff. LPA was shown a binder with reports and documents are available when requested. 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 and a copy of this report LIC909 was given to RCD Kimberly Jones. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 9, 2023 · control 24-AS-20230626140051

Allegation investigated: Facility is in financial distress. Medication was accessible to residents in care. Staff do not ensure kitchen is clean.

On 10/9/2023 Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Kimberly Jones was contacted and met with LPA. 1. The Department investigated the allegation: Facility is in financial distress. On 7/5/23 LPA interviewed various staff members and documentation was reviewed showing due to non-payments vendors services were stopped and or notices were issued informing utilizes were going to be turned off. The Department was not informed of the financial distress of the facility. Substantiated 2. The Department investigated the allegation: Medication was accessible to residents in care. LPA interviewed staff who stated there was an incident where medication from one resident was left in another resident’s room unattended. This incident occurred in the Generations area where there are dementia residents. No documentation was maintained regarding the situation. 3. The Department investigated the allegation: Staff do not ensure kitchen is clean. The facility was previously cited for facility is dirty on 7/5/23. Please reference complaint # 24-AS-20230306123828 to view citing. The above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, and was previously cited. The kitchen was noted in this complaint. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D Two citations were issued today for the three allegations listed above since one allegation was previously cited on 7/5/23 it was not cited again today. Exit interview was conducted and a copy of this report LIC909 , LIC9099D, and appeal rights were given to RCD Kimberly Jones. This report has been amended. A copy of the amended report LIC809 was provided to Kelly Reynolds.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 24-AS-20230626113948

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Oct 10, 2023

87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency. Such request shall explain the need for disclosure. The licensing agency reserves the right to reject any financial report and to request additional information or examination including interim financial statements. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to maintain finances due to unpaid bills which stopped services from vendors and received potential shut-off notices from utility company. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: LPA met with Business Office Director who provided verifiation of payment for outstanding bills.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 10, 2023

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (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: Based on observation, interview, & record review the licensee failed to keep medication inaccessible to residents in care. This poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: Facility had staff inservice regarding medication. RCD will provide verficiation to LPA.

Allegation investigated: Facility is in disrepair Facility is unsanitary Staff failed to provide a comfortable environment for residents

On 10/9/2023 Licensing Program Analyst B. Miranda arrived at the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Kimberly Jones was contacted and met with LPA. 1. The Department investigated the allegation: Facility is in disrepair. LPA toured the facility and did not find the facility to be in disrepair at the time. There was water damage that was being repaired in the Redwood Dining area. On 7/5/23 this allegation was previously Unsubstantiated on complaint # 24-AS-20230306123828 regarding the facility is in disrepair. There were multiple complaints overlapping with one another. Multiple complaints were investigated at the same time. Unsubstantiated 2. The Department investigated the allegation: Facility is unsanitary LPA toured the facility on 7/27/23 and did not find any issues with the facility being unsanitary. LPA had previously conducted staffed interviews and spoke with residents in the common area who did not report any issues regarding this allegation. 3. The Department investigated the allegation: Staff failed to provide a comfortable environment for residents. LPA previously toured the facility on 7/5/23 and did not observe any residents to be uncomfortable. LPA spoke with residents who were in the common areas and did not have complaints to report. 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 and a copy of this report LIC909 was given to RCD Kimberly Jones.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 24-AS-20230626092401

Allegation investigated: Staff did not properly notify resident's responsible party of rate increase. Staff did not allow resident’s responsible party to participate in decision-making regarding the care and services provided to the resident.

On 10/9/2023 Licensing Program Analyst B. Miranda arrived at the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Kimberly Jones was contacted and met with LPA. 1. The Department investigated the allegation: Staff did not properly notify resident's responsible party of rate increase. LPA conducted interviews and reviewed records. Admission agreement stated there would be a certain amount of time allowed before increases took place. The facility did not follow the allowed time with proper written notice according to admission agreement. Substantiated 1. The Department investigated the allegation: Staff did not allow resident’s responsible party to participate in decision making regarding the care and services provided to the resident. LPA conducted interviews and reviewed records. Facility did not follow the admission agreement which stated there would be a certain amount of time allowed before changes to resident's care took place. The facility did not follow the admission agreement with proper written notice given to reporting party. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8 & HSC 1569.655 are being cited on the attached LIC 9099D Exit interview was conducted and a copy of this report LIC909 , LIC9099D, and appeal rights were given to RCD Kimberly Jones.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 24-AS-20230807083425

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655 · Plan of correction due date: Oct 16, 2023

§1569.655 Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase; application of section (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This subdivision shall not apply to optional services that are provided by individuals, professionals, or organizations under a separate fee-for-service arrangement with residents. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to give responsible party the proper 60-days notice in writing of fee increase. This poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: ED will continue to notify promptly to notify of any increases. Explaination will be sent to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Oct 16, 2023

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee failed to follow the notice agreement listed in the admission agreement when making changes to resident in care. This poses a potential health, safety, or personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: ED will clarify and confirm with legal POA to note primary contact. Will document elder mark of changes in sysytem. Email explaining

Allegation investigated: Staff does not ensure resident's pressure injury is cleaned. Staff does not respond to resident's call button in a timely manner. Facility does not have adequate staffing to meet resident's needs.

On 8/24/23 at 1:08 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the findings of the allegations listed above. LPA introduced herself to receptionist and requested to speak with the Administrator Joan Johnson. Receptionist stated Administrator was not available and all other managers were not available. Marketing Director contacted Resident Care Director (RCD) Kimberly Jones who arrived shortly after. LPA met with RCD and explained the reason for the visit. 1. The Department investigated the allegation: Staff does not ensure resident's pressure injury is cleaned. LPA conducted interviews and reviewed records. Facility was not able to provide Healthcare Plan which includes services that are provided by Home Health and which services are provided by the facility including the duration of the services. Communication log indicates there was discrepancies in Home Health Providers and resident was not getting proper care for pressure injuries. Resident was receiving care from Bridge Home Health, notes indicate facility did not know resident was discharged from Bridge Home Health since 3/28/23. LPA observed notes indicating St. Mary's Home Health, but no documents. Substantiated LPA observed documents from Valley Home Health signed 4/20/23, but no notes regarding status of care. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D 2. The Department investigated the allegation: Staff does not respond to resident's call button in a timely manner. LPA conducted interviews and reviewed records. Records show there were multiple times the resident had to wait over 18 minutes from the time R1's pendant had been pushed. Interviews conducted stated the facility is short staffed so it takes longer to respond to the residents when the pendants are pushed. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. 3. The Department investigated the allegation: Facility does not have adequate staffing to meet resident's needs. LPA conducted interviews where it was stated the facility is short staffed so it is hard to meet the resident's needs adequately. On 4/12/23 communication log indicates R1's catheter was leaking and a pressure injury on the buttocks was turning green and smelly. However staff did not send resident to the hospital and facility was unaware home health services were discontinued. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. During the course of this complaint investigation LPA interviewed staff on duty and obtained and/or reviewed facility records. It was determined based on the interviews and records review that the above allegations are SUBSTANTIATED. Exit interview was conducted and a copy of this report LIC909 , LIC9099D, and appeal rights were given to Resident Care Director- Kimberly Jones.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 24-AS-20230501112552

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87609(b)(2) · Plan of correction due date: Aug 25, 2023

87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (2) The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care. This requirement is not met as evidenced by: Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Facility did not take the proper steps to ensure R1's medical needs were being met with Home Health, and no completed health plan was on file.the state’s words, verbatim · CDSS document, Aug 24, 2023

Plan of correction: RCD will create a binder with plans and note care of service. Policy & procedure verification will be sent to LPA 8/31/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87623(b)(2) · Plan of correction due date: Aug 25, 2023

87623 Indwelling Urinary Catheter (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. (B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed. This requirement is not met as evidenced by: Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Staff at the facility was not adequate to care for R1 and send to hospital when needed. Interviewees stated facility was short staff and unable to meet resident's needs.the state’s words, verbatim · CDSS document, Aug 24, 2023

Plan of correction: Staff will be inserviced on home health policy. Knowing when to call home health and send out. Home health contact information will be noted on service plan and service agreement. Policy/Procdure will be provided to LPA by 8/31/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 31, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation interview, the licensee did not comply with the section cited above Poses a potential health, safety, or personal rights risk to residents in care. LPA reviewed records which indicated there was an extended amount of time before R1's pendant call was responded to.the state’s words, verbatim · CDSS document, Aug 24, 2023

Plan of correction: Escalation procedure in place. After 15 minutes the call is escalated to GPD & RCD.

Allegation investigated: Staff does not ensure resident's showering needs are being met. Staff does not provide adequate food service to resident. Staff leaves resident soiled for an extended period of time.

Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced. LPA met with Rsident Care Director Kimberly Jones and explained the reason for the visit. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Staff does not ensure resident's showering needs are being met, Staff does not provide adequate food service to resident, Staff leaves resident soiled for an extended period of time. Based on the interviews conducted and/or records review the above allegations is UNSUBSTANTIATED. Although the allegation may have happened or is 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 was conducted an a copy of this report was provided to Kimberly Jones. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 24, 2023 · control 24-AS-20230501112552

Type of visit: Case Management - Other

On 8/11/23 at 9:30 a.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management. LPA met with Resident Care Director Kimberly Jones. LPA previously received an incident report regarding R1’s death but no death report was submitted. Department must be notified by the next working day and a Death Report must be submitted within 7 days of the occurrence. Resident files are to be retained for a minimum of 3 years following termination of service to resident according to Title 22, Division 6, Chapter 8, regulation 87506 Resident Records. Facility was unable to locate the death report for R1. This deficiency is citable according to Title 22, Division 6, Chapter 8. Exit interview was conducted and a copy of LIC809, LIC809D, and appeal rights were provided to Resident Care Director- Kimberly Jones.the state’s words, verbatim · CDSS document, Aug 11, 2023

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

87211 Reporting Requirements (a) 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. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement is not met as evidenced by: Based on observation/ interview/ record review the licensee failed to provide the Department with a death report for R1. This poses a potential health, safety, or personal rights risk to residents in care. Resident files are to be retained for a minimum of three years.the state’s words, verbatim · CDSS document, Aug 11, 2023

Plan of correction: Facility will have a designated staff person to submit all death reports to the Department. Email verification of designated staff person will be sent to LPA

Type of visit: Required - 1 Year

On 7/27/2023 at 9:45 a.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an annual inspection. LPA entered the facility and was greeted by the receptionist. LPA asked to speak with Joan Johnson who is the potential administrator. Resident Care Director Kimberly Jones was contacted and informed LPA Joan was not available. LPA completed tour with Generations Program Director- Lupe Fierros. Currently the facility does not have an active Administrator. LPA toured the facility inside and out. LPA checked water temperature in resident's bathroom which read at 113.7 degrees F. LPA observed multiple fire extinguishers to last be serviced 2/21/23 and still have charge. Facility's capacity is 162, and currently there is 62 residents. All residents have their own apartments unless they are sharing with a spouse. LPA observed a sample resident bedrooms which were properly furnished, had adequate lighting, and storage space. Sample of residents stated they can control the temperature in their apartments. Verification was provided from Direct Supply indicating smoke detectors were last tested on 11/17/22. Facility was not able to provide verification of carbon monoxide detectors being tested. Due to time constraints annual inspection was not completed at this time. Deficiencies and citations will be issued at a later date. LPA will return to the facility at a later date or an appointment at the Regional Office will be scheduled. Exit interview was conducted with Resident Care Director Kimberly Jonesthe state’s words, verbatim · CDSS document, Jul 27, 2023

Allegation investigated: Staff are not following Covid-19 masking protocols Staff do not follow procedures which protect the safety of food during preparation and service. Facility is dirty. Staff do not respond to resident's requests for assistance in a timely manner. Staff do not ensure that resident is given the correct medication.

On 7/5/2023 at 1:50 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit with Senior Director of Sales & Marketing Gaby Alvarado. 1. The Department investigated the allegation: Staff are not following Covid-19 masking protocols. LPA toured the facility and found some employees to either not be wearing a mask or wearing the mask incorrectly. At this time is was still mandatory for all employees to wear masks while working in the facility. 2. The Department investigated the allegation: Staff do not follow procedures which protect the safety of food during preparation and service. LPA toured the facility on various occasions and found kitchen staff to not be wearing gloves while preparing food and to be without hairnets. LPA requested multiple time for training of kitchen staff and kitchen staff contact information which was never provided. Substantiated 3. The Department investigated the allegation: Facility is dirty. 4 Staff interviews were conducted and LPA observed areas of the facility not being maintained. Widow sills in the dining area need to be cleaned. Madera room needs to be cleaned and maintained residents are able to access room. Ice machine has mold and kitchen needs to be cleaned and maintained. 4. The Department investigated the allegation: Staff do not respond to resident's requests for assistance in a timely manner. LPA observed call pendent logs which showed at times calls were not being answered timely and would take up to an hour after the button was pushed to respond. 5. The Department investigated the allegation: Staff do not ensure that resident is given the correct medication. LPA conducted 3 interviews and observed MARS and centrally stored medication log. Centrally stored medication log was not completed and MARs was not being completed properly. LPA and staff were unable to verify start dates for some medication and bubble packs showed medication was not taken and there was no documentation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D Exit interview was conducted and a copy of this report, LIC9099C, & LIC9009D were provided to Senior Director of Sales & Marketing Gaby Alvarado.the state’s words, verbatim · CDSS document, Jul 5, 2023 · control 24-AS-20230306123828

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555 · Plan of correction due date: Jul 6, 2023

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed kitchen staff while preparring food to not be wearing gloves or hairnets.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Facility will schedule an inservice meeting regarding issues in the kitchen. Inservice meeting will be conduct by 7/14/23 and verification will be sent to LPA by 7/14/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 6, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed dirty widow sills in the dining area, Madera room is dirty (needs be cleaned and maintained due to residents having access room), ice machine has mold, and kitchen needs to be cleaned and maintained.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Ice machince will be shut off to allow ice to melt and have a deep cleaning. Meet with Maintance and schedule cleaning of areas listed. On or before 7/14/23 items listed will be cleaned and verification will be sent to LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jul 6, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed resident medication logs which were not completed properly. Staff could not explain why medication had not been given to resident.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Facility will submit plan to correct issue. Plan/training will be completed by 7/14/23. Verification will be sent to LPA

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 6, 2023

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed pendent logs which indicated there are times resident had to wait up to an hour to be assisted.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Facility will submit plan to correct issue. Plan/training will be completed by 7/14/23. Verification will be sent to LPA

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 14, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During the tour of the facility LPA observed Kitchen manager in the kitchen with the mask under their chin, 1 staff member in an office coming in and out of the office without a mask, 1 contracted maintenance person without a mask. As LPA observed 2 more staff members wearing masks under their nose.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Memo will be issued to employees to remind of infection control policies.

Allegation investigated: Facility is in disrepair.

On 7/5/2023 at 1:50 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit. Senior Director of Sales & Marketing Gaby Alvarado 1. The Department investigated the allegation: Facility is in disrepair. LPA conducted 4 staff interviews and toured the facility. LPA observed certain areas of the facility needing to be cleaned. Repairs were being completed in Redwood Room. 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 and a copy of this report was given to Senior Director of Sales & Marketing Gaby Alvarado Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 5, 2023 · control 24-AS-20230306123828

Allegation investigated: Personnel records are not adequately maintained by staff

On 7/5/2023 at 1:50 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit and met with Senior Director of Sales & Marketing Gaby Alvarado. 1. The Department investigated the allegation: Personnel records are not adequately maintained by staff. LPA interviewed staff members and observed a sample of personnel records. Relias is the system used for training. 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 completed and a copy of this report was provided to Gaby Alvarado. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 5, 2023 · control 24-AS-20230329140137

Allegation investigated: Staff did not safeguard resident's records Staff do not provide adequate supervision to prevent residents from leaving the facility

On 7/5/2023 at 1:50 p.m. Licensing Program Analyst B. Miranda arrived to the facility unannounced to deliver the finding for the allegations listed above. LPA introduced herself and explained the reason for the visit and met with Senior Director of Sales & Marketing Gaby Alvarado 1. The Department investigated the allegation: Staff did not safeguard resident's records. During a tour of the facility LPA noticed the top half of the Medication room was not locked and was able to be unlocked from the bottom and client's records were accessible. Administrator (Shawniee Jackson) asked staff why the medication door was left open, and staff stated because they just came out of the Med Room. LPA observed Med-Tech walking from an area of a resident's rooms and not the med room. Substantiated 2. The Department investigated the allegation: Staff do not provide adequate supervision to prevent residents from leaving the facility. During an interview with the Administrator (Shawniee Jackson), stated a resident has been able to get outside the facility through the front doors and into the parking lot. This resident belongs to memory care and should be accompanied by staff when leaving memory care. Administrator stated the furthest any resident has been able to get is the parking lot. LPA asked if the incidents were reported and Administrator stated no because they did not know they had to. LPA explained anytime an incident occurs and a resident is some where they are not supposed to be it should be reported to licensing. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D Exit interview was conducted. A copy of LIC9099, LIC9099C, and LIC9099D have given to Gaby Alvaradothe state’s words, verbatim · CDSS document, Jul 5, 2023 · control 24-AS-20230329140137

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 14, 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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Administrator at the time informed LPA resident from Generations (Memory Care) was able to get out the facility and into the parking lot without staff being aware.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Ensuring staff are aware of who residents are in Generations. Verification of in-service/memo will be sent to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Jul 14, 2023

87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed door not locked where resident's records are kept making them accessible to anyone.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Facility will have in-service/memo with Med-Tech staff. Verification of in-service/memo will be sent to LPA.

Type of visit: Case Management - Other

On 6/29/23 at 11:35 a.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management regarding the administrator at the facility. LPA introduced herself and explained the reason for the visit. Resident Care Director (RCD) Marilyn Couzens was contacted. Previously on 6/14/23 LPA was informed Administrator on file Shawniee Jackson is longer working at the facility. LPA was informed Shawniee’s last day at the facility was 5/30/23. Facility has 30 days to provide proper verification of a certified Administrator, which will end 6/30/23 Facility has not provided verification of certified administrator at this time. Facility was informed verification needs to be provided by end of business day 7/3/23. Exit interview was conducted and a copy of this report was provided to Marilyn Couzens.the state’s words, verbatim · CDSS document, Jun 29, 2023

Allegation investigated: Facility staff did not properly manage a resident's medication.

On 6/14/2023 at 1:23 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to open a complaint and conduct an investigation. LPA met with Resident Care Director Marilyn Couzens and explained the reason for the visit. LPA collected sample Centerally Stored Medication log, communication log, and Med Tech procedures. Marilyn will provide staff schedule for June and staff contact information by end of business day 6/19/23. 1. The Department investigated the allegation: Facility staff did not properly manage a resident's medication. LPA interviewed staff members and reviewed a sample of resident records. LPA observed Centerally Stored Medication log to not be completed. Bubble packs did not have date medication started and incorrect amount of medication in container. Substantiated Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D Exit interview was completed and a copy of this report and LIC9099D was provided to Marilyn Couzensthe state’s words, verbatim · CDSS document, Jun 14, 2023 · control 24-AS-20230612102501

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jun 15, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA reviewed Centrally Stored Medication log which was incomplete and amount of medication in container had more medication then should have been from the filled date.the state’s words, verbatim · CDSS document, Jun 14, 2023

Plan of correction: Notice will be given to Med-Techs to properly log medication. All staff meeting on 6/22/23 will have training regarding medication.

Type of visit: Case Management - Other

On 6/14/2023 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management. LPA met with Resident Care Director Marilyn Couzens introduced herself, and explained the reason for the visit. During the visit LPA was informed Administrator Shawinee Jackson was not longer the administrator and S1 was the Interim Administrator. LPA reviewed records and did not find S1 to have proper clearance to work at the facility. Citation was issued under Title 22, Division 6, Chapter 8. Exit interview was conducted, a copy of this report and LIC809D were provided to Marilyn Couzens.the state’s words, verbatim · CDSS document, Jun 14, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jun 15, 2023

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Based on observation interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed uncleared staff S1 to be in the facility without proper clearance.the state’s words, verbatim · CDSS document, Jun 14, 2023

Plan of correction: S1 will have to leave the facility and will not be able to return until back ground clearance has been completed.

Type of visit: Case Management - Other

On 3/10/2023 at 1:10 p.m. Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct a Case Management. Case Management is being conducted in response to information received on 3/8/2023 regarding a previous outbreak at the facility from 11/2022-12/2022. LPA was greeted by receptionist and allowed entry into the facility. LPA requested to speak with Administrator (AD) Shawniee Jackson. AD was contacted and met with LPA. LPA explained the reason for the visit. LPA reviewed previously submitted incident reports from the facility and the Covid-19 log kept at the facility. The number of positive Covid-19 cases listed on the incident report and sent to CCLD do not match the number of positive cases listed on the log. The log indicates for the month of November 2022 there were 33 positive Covid-19 cases from 11/6/22-11/11/22. Citation was issued today under Title 22, Division 6, Chapter 8, Article 04, Operating Requirements Exit interview was completed. A copy of this report and LIC809D were provided to AD.the state’s words, verbatim · CDSS document, Mar 10, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Mar 22, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: Based on observation, interview, and file review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed documents which did not match the number of positive COVID-19 cases with the number of cases reported to CCLD (Outbreak)the state’s words, verbatim · CDSS document, Mar 10, 2023

Plan of correction: AD agrees to submit a statement of understanding of CCLD PINs and submit to CCLD by due date.

Allegation investigated: Resident sustained injuries from falls while in care Staff mishandled a resident's medication Staff overmedicated a resident while in care

On 03/07/23, Licensing Program Analyst (LPA), L. Salazar arrived to the facility unannounced to deliver findings on the above allegations. LPA was greeted by receptionist, stated the purpose of the visit and was allowed entry into the facility. During the investigation, LPA conducted interviews and records review. Based on the information received and although the allegations may have happened, there is not a preponderance of evidence to prove that the alleged violations occurred, therefore the allegations are Unsubstantiated. When Resident R1 was admitted to hospice care services, the facility did not receive a discontinue order for medications. Facility was continuing to follow doctor's order. Facility provided extra care and supervision and documented contact with the hospice agency regarding R1's condition. Nothe state’s words, verbatim · CDSS document, Mar 7, 2023 · control 24-AS-20221011105453

Type of visit: Case Management - Other

On 02/23/23, Licensing Program Analyst (LPA) V Gorban conducted an unannounced Case Management visit. LPA introduced self and was allowed entrance by staff. LPA met with Executive Director (ED) Shawnee Jackson and stated reason for visit. LPA arrived at the facility to conduct case management visit to relay information about Immediate Exclusion order for Staff (S1). LPA verified with ED that S1 has not worked in facility since S1 was not completed physical examination. Administrator responded that S1 has not been with the facility or worked for Cedar Creek. Executive Director was advised an exclusion has been ordered and issued by the Department and provided an exclusion order document for the facility stated above. Per ED S1 was never associated with the facility personnel and report provided by LPA. LPA also provided the ED with a copy of the Decision and Order. No deficiencies sited during this Case Management visit. An exit interview was conducted, and report signed on-site, and a copy of report will be provided for the facility records.the state’s words, verbatim · CDSS document, Feb 23, 2023

Type of visit: Case Management - Incident

On 08/26/22, Licensing Program Analyst (LPA) L. Salazar arrived unannounced to conduct an case management visit based on reporting requirements. LPA was greeted by Executive Director, stated purpose of visit. COVID precautionary measures were taken at the time of entry. LPA entered through the central entry point where hand sanitizer and visitor policy was posted. LPA observed the Staff and Visitor sign in and Covid Symptom Screening area. On 08/03/22, LPA observed an incident reported dated 07/26/2022. This reporting was a day late. LPA requested a copy of an incident report that occurred on 06/20/22. No report was submitted. LPA toured the facility. Facility's census shows 75 residents in the Assisted Living area of the building and 11 residents in the Generations unit which is designated for Memory Care (MC). During the tour of the MC unit, LPA observed sharp items accessible to residents in care. LPA requested training records for staff. Records revealed staff do not have the required training for dementia care. In accordance with Title 22, California Code of Regulations , the following deficiencies are being cited on the attached LIC 809D. All violations that, if not corrected, will have a direct immediate and/or potential risk to the health, safety or personal rights of clients in care. Exit interview was conducted with ED. A copy of the 809, 809-D and appeal rights were provided to Executive Director.the state’s words, verbatim · CDSS document, Aug 26, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Aug 29, 2022

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). This requirement was not met as evidenced by LPA's observation of a screwdriver, hammer, meat thermometer, pizza slicer and wood skewer sticks accessible to residents in care. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2022

Plan of correction: ED removed items from cabinets and locked items so they are not accessible. ** POC Cleared**

From the deficiency page — Deficiency type: Type B · Section cited: CCR87707(a)(2) · Plan of correction due date: Sep 12, 2022

87707 Training Requirements If Advertising Dementia Special Care, Programming And/Or Environments (a) Licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall ensure that all direct care staff, described in Section 87706(a)(1), who provide care to residents with dementia, meet the following training requirements: (2) Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period...Direct care staff hired as of July 3, 2004 shall complete the eight hours of in-service training within 12 months of that date and in each succeeding 12-month period. This requirement was not met as evidenced by LPAs review of training records. 5 out 5 staff did not have the required training.the state’s words, verbatim · CDSS document, Aug 26, 2022

Plan of correction: ED will provide documentation evidencing an all staff training was provided by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 12, 2022

(a) 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. This requirement was not met as evidenced by LPAs observation of an incident report dated 07/26/22 was sent late. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2022

Plan of correction: ED will provide proof of the all staff training for reporting requirements by POC date.

Type of visit: Required - 1 Year

On 08/16/22, Licensing Program Analyst (LPA) L. Salazar arrived unannounced to conduct the required Annual - Infection Control Inspection. LPA was greeted by Executive Director, stated purpose of visit. COVID precautionary measures were taken at the time of entry. LPA entered through the central entry point where hand sanitizer and visitor policy was posted. LPA observed the Staff and Visitor sign in and Covid Symptom Screening area. Facility Mitigation plan has been submitted to CCL. Infection control procedures described in the plan were observed and reviewed with LPA include: Daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, emergency staffing plan, PPE storage, use and training, as well as daily infection control procedures. The Executive Director is identified as the Infection Control lead for the facility. LPA toured the facility and observed postings to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Staff were all observed wearing face coverings. Facility has multiple designated visitation areas available. LPA observed PPE accessible to staff. Common and resident bathroom sinks are well stocked with liquid soap and paper towels for hand washing. Through LPA’s observations, documentation review and interview with Executive Director, the required infection control practices are found to be in compliance. No deficiencies cited on today’s inspection.the state’s words, verbatim · CDSS document, Aug 26, 2022

Allegation investigated: Resident fell multiple times while in care as the result of neglect, sustaining a fracture and hematoma.

On 02/18/22, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above complaint allegation. LPA was greeted by front desk staff, stated the purpose of the visit, and was allowed entry into the facility. COVID precautionary measures were taken prior to LPA entering the facility. The Department has investigated the above allegation. Through interviews and records review that were conducted, it was documented that Resident R1’s health began to decline. R1 was admitted to Hospice on 09/21/21 and moved to the “Generations” Memory Care unit. It was documented that R1 had been non-compliant in using their walker for ambulation. The facility responded immediately, called 911 and sought medical treatment for R1. Although the allegation may have happened, there is not a preponderance of evident to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and copy of report was left with Executive Director. Nothe state’s words, verbatim · CDSS document, Feb 18, 2022 · control 24-AS-20210924163703

Allegation investigated: Staff are mismanaging resident’s medications. Care and supervision is not being provided to residents while in care. Facility had inadequate diapering supplies. Facility has a rodent infestation.

On 02/18/22, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above complaint allegations. LPA was greeted by front desk staff, stated the purpose of the visit, and was allowed entry into the facility. COVID precautionary measures were taken prior to LPA entering the facility. During the investigation, LPA reviewed pest control records, medication records, staffing schedules, facility procedures and conducted interviews with staff, residents, and Executive Director. Based on the information received, the Department has found that the complaint was unfounded, meaning that the allegations are false, and/or is without reasonable basis. Nothe state’s words, verbatim · CDSS document, Feb 18, 2022 · control 24-AS-20211005112928

Type of visit: Case Management - Deficiencies

On 12/17/21, Licensing Program Analysts (LPA's) L. Salazar and M. Garza arrived at the facility unannounced to conduct the required 10 day site inspection for complaint allegations. COVID precautionary measures were taken at the point of entry. LPA met with Lead Concierge, Debra Sanchez and stated the purpose of the visit. Executive Director, Shawnie Jackson has left for the day but has given the above staff authorization via telephone to sign reports. LPAs' toured the facility. LPAs' observed a furniture blocking 2 out of the 4 exit doors located in the Generations (Memory Care Unit) that are identified as evacuation exits in a case of emergency. LPAs' observed uncompleted construction in the Lobby of the facility and also resident's hallway next to the lobby. In accordance with Title 22, California Code of Regulations , the following deficiencies are being cited based on LPAs observations. See LIC 809D. All violations that, if not corrected, will have a direct immediate and/or potential risk to the health, safety or personal rights of clients in care. Exit interview was conducted with Debra Sanchez. A copy of the 809, 809-D and appeal rights will be provided to Executive Director via email by next business day.the state’s words, verbatim · CDSS document, Dec 17, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Dec 20, 2021

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by LPA's observations and pictures of furniture intentionally blocking the exit doors in the Gernerations (memory care unit).the state’s words, verbatim · CDSS document, Dec 17, 2021

Plan of correction: Executive Director (ED) will remove the couches and tables that are blocking two of the exit doors in the Generations (memory care) unit immediately. ED will hire more staff for additional surpervision if need be to comply with care and supervision needs.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Dec 31, 2021

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by LPA's observations of facility lobby and hallway to resident's room being in disrepair and under incomplete construction at the base of the walls.the state’s words, verbatim · CDSS document, Dec 17, 2021

Plan of correction: Executive Director (ED) shall submit a written letter indicating compliance with the regulations by POC date.

Type of visit: Case Management - Deficiencies

On 10/13/2021, Licensing Program Analyst (LPA) arrived at the facility to conduct a 10-day required site inspection. During the course of the inspection, LPA toured the kitchen and observed the following: LPA observed boxes blocking pathway to pantry shelves. Plastic bins in the pantry containing pancake mix, and flour were observed to be uncovered and exposed to environment. LPA observed green Jell-O and rice pudding stored in the walk in fridge with no cover, exposed to environment. LPA observed ice cream in freezer to be uncovered. Based on the LPA's observation, California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87555 was not met. Deficiencies are being cited on the attached LIC 809-D. Deficiencies are being cited on the attached LIC 809-D. Exit interview was conducted. A copy of this report and appeal rights were given.the state’s words, verbatim · CDSS document, Oct 13, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(23) · Plan of correction due date: Oct 14, 2021

87555 General Food Service Requirements (b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement was not met as evidenced by Plastic bins in the pantry containing pancake mix, and flour were observed to be uncovered and exposed to environment.the state’s words, verbatim · CDSS document, Oct 13, 2021

Plan of correction: Facility immediately cleaned the lids that were located on the floor and covered the bins wth tight fitting lids. **POC Cleared**

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(28) · Plan of correction due date: Oct 14, 2021

87555 General Food Service Requirements (b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement was not met as evidenced by LPA's observation of green Jell-O and rice pudding stored in the walk in fridge with no cover, exposed to environment. LPA observed ice cream in freezer to be uncoveredthe state’s words, verbatim · CDSS document, Oct 13, 2021

Plan of correction: Facility immediately discarded the left over food into the trash bin. *** POC cleared***

Type of visit: Case Management - Other

On 9/29/2021 Licensing Program Analyst (LPA) M. Garza arrived at facility and met with Executive Director (ED), Shawniee Jackson for a case management to return files. Upon entry into the facility LPA observed construction work that has taken place in the faciilty and office area. The sheet rock was removed and exposing the 2x4's inside the walls. LPA addressed reporting with ED. LPA also addressed a SOC 341 that was submitted by a third party on 9/10/2021 for Resident (R1). During LPA observation it was noted that this incident was not reported to CCL. The following deficiencies are being cited: Title 22, Division 6, Chapter 8, Section 87211(a)(1)(D). Refer to 809D. A plan of correction was discussed with the Executive Director. An exit interview was conducted. Appeal Rights discussed. A copy of this report and Appeal Rights were emailed due to COVID precautionary measures being taken. A delivered and read receipt serves as confirmation.the state’s words, verbatim · CDSS document, Sep 29, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 17, 2021

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...: (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... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: Interview conducted with Executive Director and observation that no verification the incident was reoirted or submitted to CCL.the state’s words, verbatim · CDSS document, Sep 29, 2021

Plan of correction: The POC from ED is to have training completed on 10/5 and 10/6/21 for the ED and Licensing Vocational Nurse (LVN). Complete training with all other staff and documentation sent to CCL no later than 10/17/21. Continue ongoing training/education with all staff regarding mandated reporters and elderly abuse every 6 months with documentation submitted to CCL.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct the Infection Control Inspection. LPA met with Executive Director, Shawniee Jackson completed the Covid Contact questionnaire. LPA entered through the central entry point where hand sanitizer and visitor policy was posted. LPA observed the Staff and Visitor sign in and Covid Symptom Screening area. Facility Mitigation plan has been submitted to CCL. Infection control procedures described in the plan which were observed and reviewed by LPA include: Daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, emergency staffing plan, PPE storage, use and training, as well as daily infection control procedures. The Executive Director and Maintenance Director is identified as the Infection Control Lead for the facility. LPA toured the facility inside and out. Postings to encourage face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. Staff were all observed wearing face coverings. Facility has multiple designated visitation areas available. LPA observed 30-day medication supply and PPE accessible to staff. Common and resident bathroom sinks are stocked with liquid soap and paper towels for hand washing. Through LPA’s observations, documentation review and interview with Executive Director, , the required infection control practices are found to be in compliance. No deficiencies cited on today’s inspection.the state’s words, verbatim · CDSS document, Jul 28, 2021