Bello Gardens Assisted Living

Type of visit: Required - 1 Year

License Program Analyst (LPA’s) Hansen and Rummonds arrived unannounced to conduct an Annual Required – 1 yr. visit of the facility. LPA’s had caregiver Josefa Mancinas contact Administrator who arrived during the inspection. There is a total of 22 residents. There is 2 residents currently on Hospice and some residents with Dementia. LPA’s entered the facility with auditory alarm going off and waited in entrance room for approximately 7 minutes observing other residents walking the halls and then went to find care staff, all of which were in dining area (see LIC809-D) LPA’s toured the facility on 10/19/2023 at 9:15 AM with Josefa Mancinas; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 6/29/2023 at the time of the visit. Facility smoke detectors were tested and found to be operational at the time of the visit. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 10/5/2023. LPAs observed Carbon monoxide detectors that were found to be operational during the visit. There is a backup generator that powers many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 110.4 degrees F and 100.4 degrees F. falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 6 of 9 resident’s bathrooms while touring facility on 10/19/2023 at 10:25AM (see LIC809-D). Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPAs toured the kitchen area on 10/19/2023 at 10:00 AM; although toxins were observed stored with food in kitchen (see LIC809-D). Food is available for residents any time of the day. There is a daily activity schedule for residents. Continue on LIC809-C Toxins are stored in a locked housekeeping closet and under the kitchen cabinet; although LPA’s observed toxins in resident bathroom as well as razors. While touring outside LPA’s observed multiple cans of paint on back patio accessible to residents in care (see LIC809-D) There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. LPAs observed a strong smell of urine in downstairs common bathroom & in resident (R1) bedroom on 10/19/2023 at 10:15AM (see LIC809-D). LPA’s also observed multiple bathrooms containing communal hand towels and bathrooms without paper towels (see LIC809-D). LPA’s and Administrator observed side door to facility with shattered/taped window (see LI809-D). A sample review of five resident & five staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 11:27AM on 10/19/2023 and learned that 5 of 5 residents have update reappraisal/needs & care plan on file at this time as required by Title 22 Regulation. Medications were centrally stored in a locked medication cabinet in the facility medication room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 10/19/2023 at 2:00PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPAs conducted a sample reviewed of staff records at 12:37PM on 10/19/2023 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1st Aid certification for all staff. Neysa Hinton, Administrator Certificate # 6053696740 expires on 10/30/2024. LPAs reviewed Licensing Information System (LIS) with Administrator who stated that is current and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted quarterly with the last one being conducted on 9/29/2023. Continue to LIC809-C Appeal Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided. LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 11/9/2023: Copy of Annual Sprinkler Inspection LIC 308 Designation of Responsibility LIC 309 Administrative Organization LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator’s Certificate Proof of Liability Insurancethe state’s words, verbatim · CDSS document, Oct 19, 2023

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Office

An informal meeting was conducted today via Microsoft Teams, present in the meeting were, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst, Shannan Hansen, Owner, Mark Bello, Executive Director, Neysa Hinton, and Administrator Charleen Vierra. The purpose of the informal office meeting was to discuss concerns that have been identified by the department. The following was discussed during the office meeting: * Timely Medical - Related to complaint investigated resulted in substantiated findings, reference complaint 21-AS-20221028104235. * AWOL policy - related to recent incident of AWOL and citation issued due to following facilities elopement policy, reference case management LIC 809 on 1/26/2023 . * Eviction regulation - LPA Hansen provided eviction regulations 87224 on 1/20/2023 . Participants in this meeting have been informed that the informal meeting is part of the departments administrative process, further non compliance may result in a non compliance plan. No citations issued Original signature on file. A copy of this report was emailed to Licensee.the state’s words, verbatim · CDSS document, Feb 14, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator, Charleen Vierra. LPA is following up regarding a self reported Incident Report received on 1/24/2023 that occurred on 1/17/2023. At approximately 8:20 am R1 AWOLed from facility, could not be located and later was found by individual after falling. Individual called 911 and R1 was taken to hospital. Based on LPA's interviews R1 was AWOLed for approximately 2 hours. Per facility policy, Law Enforcement authorities are to be notified of elopement within 30 minutes, should resident not be located. LPA received conflicting statements from interviews and incident report submitted. Facility did not follow personnel requirements and or their plan of operations for elopement (see LIC 809-D). LPA requested documents to be submitted to CCL. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, Jan 26, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 27, 2023

87411(a) 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… This requirement has not been met as evidenced by: Based on records reviewed and interviews conducted, facility staff did not respond to residents elopement in an appropriate amount of time and or follow facilities Plan of Operation by contacting Law Enforcement. Records reviewed indicated that resident was a wanderer w/ dementia, not allowed to leave facility unatended. Interviews stated R1 AWOLed for aprox 2 hrs before outside individual contacted 911. Facility protocol is to contact law enforcement within 30 min.This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2023

Plan of correction: Administrator to ensure that all staff are trained in dementia care-specifically elopement procedures and policy including response to auditory alarms and contacting Law Enforcement. Administrator agreed to provide scheduled dates for all staff trainings to CCL by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a case management inspection and met with Administrator Charleen Vierra. The purpose of this case management inspection is to follow up on a phone call LPA received on 12/30/2022 and Incident report submitted to community care licensing (CCL). LPA is following up regarding a self-reported Incident Report received on 1/5/2023 regarding resident, R1 who on 12/30/2022 while getting up fell against a wall and then fell down hitting the back of head. R1 was taken to the hospital. On 12/30/2022 LPA had phone conversation with Administrator who was not wanting R1 to be discharged back to facility. During today’s visit LPA provided regulations on evictions. LPA advised Administrator proper eviction procedures to be in compliance with regulation provided. Regulation 87224 Eviction Procedures provided to Administrator There were no deficiencies cited during today’s visit.the state’s words, verbatim · CDSS document, Jan 20, 2023

Allegation investigated: Facility did not provide timely medical attention to resident in care

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation. LPA met with Executive Director Neysa Hinton as Administrator Charleen Vierra out. Complaint alleges facility did not provide timely medical attention to resident in care. On 10/20/2022 the department received an unusual incident report regarding an unwitnessed fall for resident (R1) resulting in an injury needing medical attention. On 10/28/2022 Community Care Licensing (CCL) received a report of suspected abuse regarding injury of R1 on 10/15/2022. Based on LPA Hansen’s investigation, Marin Central Police Authority report, officers arrived at facility at approximately 3:24PM to assist a resident needing medical attention. Hospice nurse informed officer that staff (S1) contacted the Hospice Agency at 2:35pm and hospice nurse arrived at 3:02pm responding to R1 sustaining a large laceration to the right front side of head. Interviews conducted by officers at the scene found that staff (S1) contacted Administrator who informed S1 not to call 911 and just to call the hospice nurse. Continue on LIC9099-D Substantiated It is indicated that R1 had sustained an injury from an unwitnessed fall at approximately 1:50pm and appropriate emergency medical attention was not contacted until 3:24pm. Based on LPAs interviews and record review R1 had a large amount of blood soaking through applied several gauze pads and nurse and Officer informed either verbally or in report that R1s skull was visible due to injury. In addition, Administrator’s statements to Marin Central Police Authority and LPA Hansen confirm Administrator did not choose to seek emergency medical attention from R1’s initial injury resulting in an approximate two hour time gap between initial injury and arrival of Emergency Medical System (EMS). R1 was transported to the ER and received medical attention and five stiches to laceration. The preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given Executive Director or Administrator will be sending R1's Hospital ER Discharge documents from hospital visit of 10/15/2022 by EOB 12/30/2022. The licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f). The Regional Office will be conducting an informal meeting to discuss concerns identified by the Department.the state’s words, verbatim · CDSS document, Dec 22, 2022 · control 21-AS-20221028104235

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 23, 2022

87465(a)(1) Incidental Medical and Dental Care. The Licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of the residents. ***This requirement has not been met as evidenced by: Based on record review, statements, documents, and interviews, at Administrators request staff did not seek emergency medical attention immediately, R1 remained at facility 2 hours with a head wound needing 5 stitches. This posed an immediate risk to the health of R1.the state’s words, verbatim · CDSS document, Dec 22, 2022

Plan of correction: Administration shall provide refresher training to all care staff regarding the requirements of 87465 and submit, by POC date, schedule and topic outline to CCL(1st due date12/23/22), with proof of training to follow within 2 weeks in order to clear the deficiency (final due date (1/4/2023).

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hansen had arrived unannounced at facility to open a complaint investigation and was greeted by Staff Elle and Mercedes. LPA toured facility with staff and observed medications stored in unlocked kitchen cabinet, accessible to residents in care (see LIC 809D). Facility is being cited per Regulation 87465(h)(2). Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Nov 4, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Nov 7, 2022

87465(h)(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. Based on LPA's observation of medicaiton and unlocked cabinet located in the kitchen, medications are accessible to residents in care. This is an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2022

Plan of correction: Administrator agrees to submit self certification that all medications are locked and inaccessable to residents in care. Administrator agrees to submit POC to CCL by 11/07/2022. & Administrator agrees to submit staff training and signature sheet to CCL by POC 11/11/2022.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a case management inspection and was greeted by staff Walter. Administrator Charleen Vierra arrived 20 minutes later. The purpose of this case management inspection is to follow up on corrections requested at facilities annual inspection. LPA toured the facility and grounds with staff Walter and observed new waterheater, and tested water temperature,which was within Title 22 Regulations of 105 - 120 degrees F. LPA observed new flooring in hallway and backyard had been cleaned up of any dangerous items that could cause injuries to residents in care. LPA reminded Administrator, documents requested at annual inspection are due. No deficiencies cited during today’s inspection.the state’s words, verbatim · CDSS document, Oct 27, 2022

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by Staff Walter Paredes. Staff contacted Administrator Charleen Vierra who arrived during the inspection. There is a total of 20 residents with 6 residents on Hospice and 13 residents with Dementia. LPA toured the facility on 10/14/2022 at 10:45AM with staff Walter, Chef, Aide. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 6/21/2022 at the time of the visit. Facility smoke detectors are hard wired and sound directly to Stanley Security which notifies Fire and Police Departments. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 8/31/2022. LPA observed Carbon monoxide detectors that were found to be operational during the visit. There is a backup generator that powers many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured 106.7, 109.2, 113.1, 113.5, 118, & 122.7 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in resident’s bathrooms while touring facility. (see LIC 809D). Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Food is available for residents any time of the day. There is a daily activity schedule for residents: scrabble, live music, balloon basketball, & salsa. Toxins are stored in a locked housekeeping closet and under the kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Continue to LIC809-C Infection Control: Facility has submitted a mitigation program plan that was approved. Posters have been placed at facility. Facility has PPE supply stored in the upstairs closet and downstairs in the kitchen and administrator’s office. Residents’ medications are centrally stored and locked in the kitchen. Facility has a 30-day supply of medication for residents. Staff had required PPE training and N95 Fit Testing. LPA reviewed Licensing Information System (LIS) with Administrator who stated that is correct and updated at this time; no need to change any of the information. Disaster Drills have been conducted quarterly with the last one being conducted on 8/16/2022. LPA advised facility to contact Marin County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA was presented with proof of current CPR & 1st Aid certification for staff. Administrator Certificate is for Charleen Vierra 6053696740 Exp. 10/2/2023 All staff have received COVID booster vaccinations. Licensee has not submitted the infection control plan. The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agrees to submit the Infection Control Plan by December 14, 2022”. LPA is issuing a Technical Assistance (see LIC 9102TA). While at facility LPA was provided a list of staff currently working. Staff (S1) was identified by LPA as not having fingerprint clearance and has worked at facility since 9/3/2022. Immediate Civil Penalties are being assessed in the amount of $500 due to staff S1 not having background check clearance and not being associated to the facility. *****Total Civil Penalties issued today in the amount of $500.00 The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Continue on LIC 809-C2 LIC 809-C 2 Appeal of Rights Given LPA Hansen is requesting Licensee to update and submit the following documents by 10/28/2021: Copy of Annual Sprinkler Inspection LIC 308 Designation of Responsibility LIC 309 Administrative Organization Articles of Corporation LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Resident’s Copy of current Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Oct 14, 2022

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Office

An informal meeting was conducted today in the Rohnert Park Regional Office via Microsoft Teams due to Covid19 precautions. Present in the meeting were, Licensing Program Manager, Bethany Moellers, Licensing Program Manager, Hope DeBenedetti, Licensing Program Manager, Kimberly Mota, Licensing Program Analyst, Shannan Hansen, Licensing Program Analyst, Caitlynn Felias, and Owner, Mark Bello, Executive Director, Neysa Hinton, Administrator Charleen Vierra, & Administrator, Jolly Carungcong. The purpose of the informal office meeting was to discuss concerns that have been identified with Fire Safety and Personal Rights violations that occurred on July 9, 2022 at this facility. The following was discussed during the office meeting: Fire Safety regulations - Personal Rights - Timely POC's - 2 extensions have been given for POC's issued 8/3/2022. LPA confirmed the citation issued on 8/3/2022 for Personal Rights is now cleared based on training submitted. Areas of concern for Greenwood Assisted Living - 216803761 can been viewed on LIC809 for facility dated 8/24/2022. No deficiencies cited for this facility. Original signature on file. A copy of this report was emailed to Licensee.the state’s words, verbatim · CDSS document, Aug 24, 2022

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator, Charleen Vierra. LPA is following up regarding a self-reported Incident Report received on 7/15/2022 regarding three residents who were being isolated due to Covid-19. Report revealed that facility staff were using towels and garbage bags wrapped around resident doors in order to contain them. On 7/9/2022 resident, R1 pulled the silent fire alarm prompting a response from the local fire department who observed the towels on the doors, per Special Incident Report. Facility is being cited today for 87203 Fire Safety violation with an immediate Civil Penalty in the amount of $500. & 87468.1(a)(6) Personal Rights violation The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, Aug 2, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Aug 3, 2022

87203 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 is not met as evidenced by: Based on records obtained and interviews conducted, licensee did not comply by restricting ability of residents to exit, which poses an immediate health, safety or personal rights risk to persons in care. **Immediate Civil Penalty assessed in the amount of $500.the state’s words, verbatim · CDSS document, Aug 2, 2022

Plan of correction: Administrator to send in written statement indicating that they understand regulation 87203 and will ensure future compliance -as proof of correction and removing towels & garbage bags from door handles by POC due date 8/3/2022. Additionally, facility will conduct an in-service for all staff regarding the regulation and submit signed & dated log for all staff to be submitted no later than 8/9/2022. **Immediate Civil Penalty assessed in the amount of $500.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(6) · Plan of correction due date: Aug 3, 2022

87468.1 (a)(6) Personal Rights of Residents in All Facilities (a) Residents in all RCFE shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by: Based on LPA record review & interviews R1 & residents, movements were restricted to the facility. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 2, 2022

Plan of correction: Administrator to ensure residents personal rights are maintained. Administrator agrees to review 87468.1 (a)(6) & provide a written plan that addresses how the facility will ensure the rights of resident to move freely at the facility by POC date 8/3/22. Licensee agrees to obtain training from an outside source for all staff on the topic of residents’ personal rights and to ensure that residents needs are being met, sign in log with dates and name of training to be submitted by 8/9/22.

Type of visit: Case Management - Other

On 5/9/2022 at 11:15 AM LPA Hansen was at this facility to amend a previous report that was generated on 5/4/2022. No citations issued.the state’s words, verbatim · CDSS document, May 9, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator Charleen Vierra who arrived approximately 45 minutes later. When LPA knocked on facility front door multiple times and no one answered, LPA walked in without any wonder guard alarms (auditory device') going off. LPA waited 7 minutes inside front entrance for staff to respond. When Administrator arrived LPA discussed requirements and regulations of safety code. The purpose of this case management inspection is to follow up on a self reported incident, SOC 341 to Community Care Licensing (CCL) received on 5/3/2022 regarding resident (R1) who has claimed was raped by a staff (S1) on 4/29/2022 and told a friend via text. Resident has Young Onset Alzheimer's Disease and recently changed doctors who then due to an obsessed appetite new doctor prescribed new medication. R1 had appreciated S1 for providing food but after the old medication wore off R1 became confused and suspicious. Facility did report incident to the local Police and Local Long Term Care Ombudsman who came out and interviewed resident and staff. CCL has requested copy of investigation. LPA conducted interviews and obtained records at todays visit. Appeal Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, May 4, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: May 5, 2022

Care of Persons with Dementia The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met by: LPA observed that the exit door to the front of the facility had the auditory high and low alarms were turned off.This is an immediate Health and Safety Risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2022

Plan of correction: Administrator to ensure that all exits are alarmed and operational at all times; ensuring the safety and well being of residents in care at all times.Administrator to submit plan of correction showing knowledge and understaning of regulation 87705 and facility procedures regarding 87705. Submit POC to Licensing by 5/5/22.

Type of visit: Case Management - Incident

*****amended report. LIC809 generated in error under this facility.the state’s words, verbatim · CDSS document, May 4, 2022

Allegation investigated: Facility staff are violating residents' rights

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of a subsequent complaint investigation resulting in delivering findings of the above allegations. LPA met with Supervising Med Technician of the day Josefa Mancinas as Administrator Neysa Hinton was not in but authorized by phone for staff to sign for her. During the investigation LPA reviewed records, made observations at the facility and conducted interviews. Facility staff are violating residents’ rights. –LPA conducted interviews with staff, outside sources, and residents during investigation, along with record reviews and observations. Complaint alleges facility did not respond to reports of abuse by staff to residents for over a year. Allegations include an incident where a resident was cut on the hand during a struggle with staff. Continued on 9099-C Unsubstantiated Due to conflicting statements and no documentation that incidents occurred LPA was unable to corroborate the above allegations, therefore the allegation is unsubstantiated This Department has investigated this complaint and determined that although the allegations Facility staff are violating residents’ rights may be true or valid, there is not a preponderance of evidence to prove the alleged violation did or did not, occur. Therefore, the allegation is deemed UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Oct 22, 2021 · control 21-AS-20210805114652

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by Walter Paredes, Food Services. Staff contacted Administrator who arrived during the inspection. There is a total of 22 residents. There is 2 residents currently on Hospice and some residents with Dementia. LPA arrived at the facility and had temperature checked and logged. All staff are temperature checked and logged each shift and wear masks. LPA toured the facility on 10/07/2021 at 12:15 PM with Walter Paredes, Chef, Aide; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 7/28/21 at the time of the visit. Facility smoke detectors are hard wired and sound directly to Stanley Security which notifies Fire and Police Departments. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 10/06/2021 LPA observed Carbon monoxide detectors that were found to be operational during the visit. There is a backup generator that powers many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 112.2 degrees F and 105.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in of resident’s bathrooms while touring facility. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen are on 10/7/2021. Food is available for residents any time of the day. There is a daily activity schedule for residents. Residents were playing balloon volleyball at time of visit and bingo was up next “stated another resident”. Continue to LIC809-C Toxins are stored in a locked housekeeping closet and under the kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Infection Control: Facility has submitted a mitigation program plan that was approved 1/28/2021. Posters have been placed at facility. Facility has PPE supply stored in the upstairs and closet and downstairs in the kitchen and administrator’s office. Residents’ medications are centrally stored and locked. Facility has a 30-day supply of medication for residents. Residents do not wear masks inside the facility. Staff had required PPE training and N95 Fit Testing. LPA was presented with proof of CPR & 1st Aid certification for staff. Neysa Hinton, Administrator CPR/1st Aid expires on 5/21/2022. LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have been conducted quarterly with the last one being conducted on 9/20/2021. LPA advised facility to contact Marin County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA Hansen is requesting Licensee to update and submit the following documents by 10/21/2021: Copy of Annual Sprinkler Inspection LIC 308 Designation of Responsibility LIC 309 Administrative Organization Articles of Corporation LIC 500 Personnel Summary LIC 9020 Register of Facility Client’s/Resident’s There were no deficiencies cited at this time.the state’s words, verbatim · CDSS document, Oct 7, 2021