Shepherd's Inn

Type of visit: Required - 1 Year

On 8/15/2023 at 12:31 p.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an annual inspection. LPA was greeted by staff. Administrator Lita Williams was contacted but will not be able to come to the facility. RJ (Marino) Pascual was contacted and arrived at the facility later. LPA toured the facility inside and out. Facility currently has 6 residents. Each resident has their own bedroom with a door leading to outside for emergency purposes, doors have alarms. LPA observed residents interacting with staff, watching TV, and in their bedrooms. LPA observed facility to have sufficient perishable and non-perishable food items. LPA observed some canned food items to be expired. LPA observed food at facility to not be labeled properly. LPA was not able to distinguish between residents’ food and live in staff food. LPA observed one drawer in the kitchen had scissor which were not locked. Garage/storage door was not locked, this gave residents access to knives. LPA observed cleaning supplies under the kitchen sink to not be locked. Sample of staff files were reviewed, and current training is missing for staff. Resident’s files were reviewed, emergency contact information needs to be completed and up to date with current doctor and dentist contact information. LPA observed centrally stored medication log to not be complete. Facility needs a Plan of Operation, Plan of Operation for Dementia, Disaster Plan, Infection Control Plan to be readily available at the facility. Exit interview was conducted. A copy of LIC809, 809D, and appeal rights were provided to staff RJ (Marino) Pascualthe state’s words, verbatim · CDSS document, Aug 15, 2023

Allegation investigated: Staff did not meet resident’s needs Staff did not seek medical attention timely Staff spoke inappropriately to resident Insufficient staffing to meet the resident’s needs

On 3/20/2022, Licensing Program Analyst (LPA) Jaclyn Avila, conducted an unannounced complaint investigation visit regarding the above allegations and met with Lita Williams Administrator/Licensee. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. California Department of Social Services (CDSS) Community Care Licensing (CCL) has investigated this complaint and following are the findings: This department reviewed medical records provided by Home Health, conducted interviews, reviewed documents, statements and communications between licensee, staff and responsible parties: Cont'd on 9099-C Substantiated Home Health Registered Nurse (RN) notated on 5/27/2021, RN instructed patient (Resident/R1) and caregiver on use of assistive devices to ensure R1 is safe, R1 is always to use assistive device when up, R1 needs stand-by assistance to ambulate at all times. Home health instructed on environmental safety issues to resolve immediate hazards, keep clear pathways, eliminate clutter, keep telephone close, remove throw rugs. Records noted R1 has a diagnosis of dementia. Home Health records notated by RN dated 6/4/2021: R1 said R1 feels as if R1 is burden to staff as R1 needs assistance to ambulate or use restroom. Per R1, R1 is told rude comments by staff and make R1 feel very uncomfortable belittled. Nurse noted there is a camera in the room to monitor R1 if abuse is happening per POA (Power of attorney). In addition to R1 revealing to home health that staff made rude comments and belittled R1, R1 made similar statements and provided examples to others. This department learned through interview and review of text exchanges scribed by Licensee Lita, on 6/8/2021, R1 landed on R1’s “tush.” Staff heard the bell and headed to R1’s room. Lita writes that when R1 doesn’t have tremors, R1 is able to get up and walk on R1’s own to the kitchen area. Lita goes on to state that, “There are times when R1 just want to be catered to and would insist that R1 would rather ride on R1’s walker.” On 6/11/21, Lita communicated that the night prior at 9PM, R1 was found on the floor and took another fall during the night. Lita communicated that night shift always puts on the monitor and was seen by staff walking. Home Health records dated 6/21/21, notated by home health occupational therapist (OT), OT conducted a Fall risk assessment which revealed R1 is at risk for falling, depends entirely upon another person to dress and bathe. R1 needs assistance to toilet and transfer. R1 is able to walk only with supervision or assistance from another person at all times. R1 is a max assist with 24-hour care/supervision. Caregivers tell R1 to wait to use the bathroom so they can assist but due to resident frequently forgetting and attempts to ambulate on R1’s own. OT noted on 7/13/21, R1 and caregiver reported a fall occurred over the weekend. R1 requires max verbal cues and tactile cues to complete task. R1 Requires caregiver assist for balance and frequent rest breaks. Caregiver educated regarding risks of decreased activity including increased falls. Cont'd 9099-C In a text dated 8/11/21, Lita states, “R1 been acting/feeling out of sorts last couple of days. I think it’s the Parkinson that’s making R1 act this way. R1 did end up being down on the floor once yesterday and again this evening. R1 gets out of bed forgetting to ring R1's bell and starts walking. on R1’s “falls" we don’t know how it happens. Yesterday we hear the noise and found R1 by the bed facing the lamp table. Tonight, R1 is in bed shortly after dinner, then, I was in the dining room doing medications for tomorrow…I heard a noise, run to R1’s room and R1 is on the floor in a sitting position leaning against the wall between the door and the cabinets where R1’s Christmas lights is the wheel chair is by R1’s feet.” In the text Lita states, R1 was not distressed and placed back in bed. Lita acknowledges R1 was not being supervised at time of fall. Licensee/administrator did not seek immediate medical attention for this fall nor was the doctor or CCL notified by Lita although she reports R1 is “acting/feeling out of sorts.” This department reviewed a picture of the area described by the licensee. The picture is of a hole in the wall where the fall is described to be. This department reviewed video of the room prior to the fall which did not reveal a hole in the wall. Lita acknowledges there was a “dent” in the wall that she had not noticed prior to the fall but does not know if that’s what caused it. R1 was diagnosed with a urinary tract infection August 16th, 2021 An incident report submitted by Lita to CCL, notates that on 8/26/21, R1 suffered a medical emergency at which time 911 was called and R1 was hospitalized. On 8/30/21 per Lita, family would like R1 to return on hospice. Lita requested and was granted an increase from 2-3 residents on hospice with CCL provided she ensured substantial compliance. R1 returned to the facility on 8/31/21 on hospice. Lita said she did not have a conversation with hospice as to the plan of care due to the short time frame. Lita did not obtain the Hospice care plan. Cont'd 9099C This department was provided with a picture of a urine saturated diaper that was taken at 12:30 AM on 9/3/21, with a message that R1 had not been changed since before 3 the day prior. This department obtained witness statements that when Lita was confronted about the lack of care, Lita admitted to being understaffed. The department learned that on 9/3/21, an additional family moved their loved one (R2) out of the facility who was also on hospice. On 9/3/21, two of the three residents on hospice were moved out of the facility by their responsible party due to lack of care and were told by Lita that she didn’t have the staffing and couldn’t find anyone to hire. On 9/17/21, Lita provided the department with staff schedules for August and September of 2021. A review of the schedules provided revealed that there was not staffing scheduled between 6pm and 11PM during the time R1 had returned from hospice. Lita stated she lives at the facility and covers during this time. Lita stated her sister Becky who is also staff lives at the facility and will respond if needed. 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 & Chapter number), are being cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.the state’s words, verbatim · CDSS document, Mar 20, 2022 · control 26-AS-20210907164214

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(1) · Plan of correction due date: Mar 21, 2022

87625(b)(1)-Managed Incontinence-Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals This requirement is not met as evidenced by Based upon document review and interview: the Licensee failed to provide 1 of 1 residents with scheduled toileting or regular reminders. Instead staff would wait for a bell or to be called by R1 who had a diagnosis of dementia. This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2022

Plan of correction: Licensee agrees to create an ADL sign off sheet for staff to include toileting. Plan will be submitted to LPA Avila on 3/21/21

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.3129(e) · Plan of correction due date: Mar 21, 2022

1569.3129(e) Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met as evidenced by: Based upon document review and interview: the Licensee failed to provide 1 of 1 residents with supervision to ensure general health, safety and well being. This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2022

Plan of correction: Licensee agrees to review regulations 87463 reappraisals and 87466 observation of resident and agrees to update the appraisal as often as needed. LIcensee agrees to keep a log of daily observations of residents in care. Licensee will submit a copy of the log to LPA Avila on 3/21/21

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(b) · Plan of correction due date: Mar 21, 2022

87463(b) Reappraisals-The licensee shall immediately bring any such changes to the attention of the resident's physician and family or responsible person. This requirement is not met as evidenced by: Based upon document review and interview: the Licensee failed to immediatly notify 1 of 1 residents physician regarding R1's falls, increase in hallucinations, or R1 "acting/feeling out of sorts" This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2022

Plan of correction: LIcensee agrees to immediately notify resident's doctors regarding any changes to see how to proceed with care of resident. Licensee agrees to create a policy and train staff. POC due 3/21/21

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(1) · Plan of correction due date: Mar 21, 2022

1569.269(a)(1) Enumerated rights; severability-Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded dignity in their personal relationships with staff, This requirement is not met as evidenced by: Based upon observation, document review and interview: the Licensee failed to treat 1 of 1 residents with dignity. R1 had a diagnosis of dementia and needed supervision and instead the licensee tied a bell to R1 and told her to summon for assistance to be toileted.This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2022

Plan of correction: Licensee agrees to bring in an outside vendor to train staff on Resident rights. Licensee will provide confirmation of scheduled training on 3/21/21. At time of training Licensee will provide LPA Avila a copy of the sign off sheet of staff in attendance.

Allegation investigated: Facility failed to provide refund.

On 3/06/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced complaint investigation visit regarding the above allegations, and met with Lita Williams Administrator/Licensee. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. California Department of Social Services (CDSS) Community Care Licensing (CCL) has investigated this complaint and found the allegation to be unfounded. This department has reviewed the admission agreement signed by both licensee and power of attorney dated 05/21/2020. The admission agreement requires a 30 day notice from the resident (R1) and/or responsible party. In this case the responsible party paid the agreed upon amount for the month of September 2021 and gave a 30 day notice on August 31st, 2021. Responsible party then moved and discharged the resident from the facility on September 3rd, 2021. At the time of R1's death, the decedent was no longer a resident of Shepherd's Inn which does not entitle the responsible party to a prorated refund. Unfounded This agency has investigated the complaint alleging facility failed to provide refund. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basisthe state’s words, verbatim · CDSS document, Mar 6, 2022 · control 26-AS-20211001124427

Type of visit: Case Management - Deficiencies

On 3/06/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced complaint investigation visit and met with Lita Williams, administrator. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Upon arrival at approximately 11:30 AM, LPA observed a large pumpkin outside of the facility entrance. The pumpkin obstructed the pathway of an exit door to a resident bedroom. LPA entered the facility and did not observe any staff or residents wearing face coverings. LPA was not screened for COVID 19 symptoms. LPA met with Licensee/Administrator Lita Williams to conduct a complaint investigation. LPA requested a copy of the facility map which Lita was unable to produce. LPA requested Lita provide LPA with a tour of the facility, LPA observed the following deficiencies: At 11:51AM, LPA toured resident's (R1) room and observed a commode blocking the exterior exit door. LPA opened the door and observed the large pumpkin obstructing the exit. The pumpkin took up half of the width of the door way. At 11:53 AM, LPA observed cleaning supplies accessible to residents in care. The chemicals consisted of Bleach, Gain, Windex, Tide Pods, etc. These items are kept in a cabinet above the washer and dryer in a hallway that consist of 3 resident rooms. The cabinet had the ability to lock however was not secured. At 11:57 AM, LPA observed a fire extinguisher in the hallway near the laundry room that had not been signed off as inspected monthly however it was serviced in the last year. Cont'd on LIC 809-C At 11:57 AM, LPA observed a fire extinguisher in the hallway near the laundry room that had not been signed off as inspected monthly however it was serviced in the last year. At 11: 59 AM LPA toured a bedroom being occupied by a resident (R2) on hospice . Below the residents bed was an open faced heater that was not screened. LPA observed a camera on the R2's dresser facing R2. LPA observed that it was plugged in with the light on. Lita stated that it was not in use due to it not being allowed. Lita then unplugged the camera. At 12:03 PM, LPA observed the corresponding monitor on a table in the dining room that was plugged in and on. The monitor has the ability to monitor auditory and visually. At 12:01 PM, LPA requested Lita to open a cabinet that is the dining room that would be accessible to residents in care. In this cabinet, LPA observed supplements such as Collagen, Lutemax, and Magnesium. LPA observed a Coach paper bag that contained prescription medications for staff (S1). At 12:04 PM, LPA observed razors and Clorox wipes on the kitchen counter. In a desk located across from the kitchen bar, LPA requested Lita open the top drawer as its accessible to residents in care. LPA located several kitchen knives in that drawer. At 12:06 PM, Lita shared that she has difficulty with opening locks so she instead has used a D-shaped carabiner which hooks around the cabinet handles however does not have a locking mechanism. Lita opened this cabinet and inside were pre poured medications. LPA reviewed regulation 87465 -Incidental Medical and Dental Care-(h)The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. At approximately 12:50 PM, Lita walked away to obtain documents and left a cabinet containing medications opened and accessible. LPA requested an updated copy of the LIC 610E Emergency Disaster Plan for Residential Care Facilities for the Elderly. The most recent copy Lita could produce was from 2011. LIC 610E due by COB on 3/7/2022. The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 9099D or 809D). Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.the state’s words, verbatim · CDSS document, Mar 6, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Mar 7, 2022

87307-Personal Accommodations and Services-(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based upon observation the Licensee failed to keep both the exterior and interior passage way to an emergency exit free from obstruction This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2022

Plan of correction: LIcensee agrees to remove the obstructions by all passageways by COB on 3/7/2022. Licensee will send photos to LPA when POC is complete.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Mar 7, 2022

87309 (a)- Storage Space-Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced By: Based upon observation the Licensee failed to keep disinfectans and cleaning solutions stored inaccessible to residents in care This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2022

Plan of correction: Licensee locked disinfectancts and cleaning solutions during site visit. POC completed.

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

87465(h)(2)-Incidental Medical and Dental Care-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. This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to keep medication centrally stored and locked so that it is no accessible to 5 of 5 residents in care. This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2022

Plan of correction: LIcensee agrees to replace the lock where medications are kept. THis will be done no later than 3/7/2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Lita Williams Administrator. LPA toured the facility inside and out to include the entry, bedrooms and bathrooms, kitchen, dining room and living room and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in locked cabinet in the dining room. Toxins, cleaning supplies, knives and sharp objects are secured. Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products. Hand washing signs were posted in bathrooms. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE). LPA reviewed the facility policies and procedures to include screening, isolation, disinfecting, staffing, training, supplies, PPE usage and social distancing. No citations were issued per the California Code of Regulations, Title 22. LPA reviewed report with Lita Williams Administrator and a copy provided.the state’s words, verbatim · CDSS document, Jul 12, 2021