Eskaton Village Grass Valley

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday April 6, 2023 to conclude the annual inspection. LPA wore a surgical mask during todays inspection. During today's visit, the Compliance and Regulatory Enforcement Tool was used. LPA completed the CARE Tool for the annual inspection. LPA obtained a copy of the staff evacuation chair training. LPA is requesting a copy of the facility's current LIC500, LIC610E, and current liability insurance by the end of the month. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator. .the state’s words, verbatim · CDSS document, Apr 6, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Melissa Parks and Sarah Benson arrived on Monday April 3, 2023 to conduct the annual inspection. LPAs wore an surgical masks during todays inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (13) and staff files (9). All resident files contained the required paperwork. All staff have current first aid training. Facility had a full supply of PPE including face shields, surgical masks, N95s, and gowns. Facility was clean and well organized. Facility is current on fire drills. LPAs and Administrator Alicia toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, common areas, and memory care. This inspection will be concluded on a further date. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator. .the state’s words, verbatim · CDSS document, Apr 3, 2023

Type of visit: Case Management - Other

LPA Parks arrived on Tuesday January 24, 2023 to conduct an unannounced case management visit. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. Prior to the 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) N95. LPA met with Sydney, Assistant to the Executive Director, and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 01/24/2023 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Jan 24, 2023

Allegation investigated: Facility staff did not adhere to COVID-19 protocol Faciltiy does not have adaquete staff to meet the needs residents' needs

LPA Parks arrived on Monday December 12, 2022 to conduct a complaint investigation regarding the above allegations. Prior to the visit, LPA completed the 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. LPA discussed the allegations with the Administrator. Additonally, LPA interveiwed staff and obtained staffing schedules. LPA learned the following: while there was an event in November to celebrate the facility's 20th anniversary, all proper covid precuations were followed. Interviews revealed that children and guests were wearing masks at all times. Additonally, while the children performed 4 songs for the residents, masks were. The facilty had children's masks on hand, but were not needed as the children arrived with masks. While the facility has had a current covid outbreak, this was traced back to a resident's event outside of the facility. Unfounded LPA obtained a copy of the December staffing schedule as well as the daily staff schedule for AL and MC. LPA interviewed staff regarding current staffing. Staff interviews revealed that if there is an open shift, facility will utilize staffing agency to assist. The facility currently can obtain agency staff from 4 agencies. No interviews revealed insufficient staffing which resulted in a resident not being assisted from a fall. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at the facilitythe state’s words, verbatim · CDSS document, Dec 12, 2022 · control 25-AS-20221205155358

Allegation investigated: Facility's Emergency Disaster Plan is not sufficient

On 6/16/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Cameron Uhlir, to conclude a complaint investigation into the allegations listed above. LPA wore an N-95 mask and was screened by facility upon entry. Facility staff wore masks while on the premises. During the investigation, the Department reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility's Emergency Disaster Plan is not sufficient ** Report continued on 9099-C ** Unfounded During inspection conducted on 6/16/2022, LPA Hood reviewed the facility's Emergency Disaster Plan for Residential Care Facilities for the Elderly (LIC 610 E). LPA determined Emergency Disaster Plan to be sufficient in relation to Title 22 regulations. Based on records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with ED and a copy of this report was provided to the facility. The signature of the ED on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 16, 2022 · control 25-AS-20211228132044

Allegation investigated: Facility did not supply heat to residents' bedrooms

On 6/16/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Cameron Uhlir, to conclude a complaint investigation into the allegation listed above. LPA wore an N-95 mask and was screened by facility upon entry. Facility staff wore masks while on the premises. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility did not supply heat to residents' bedrooms ** Report continued on 9099-C ** Substantiated During the investigative process, the administrator, eight staff persons, the Local Long-Term Care Ombudsman (LTCO), and three residents were interviewed. Numerous documents were obtained for review and included the facility's Emergency and Disaster Plan, Disaster Plan Summary, Floor Plan, Emergency Procedures, Food Services/Emergency Disaster Plan, Emergency Contact Numbers, and Sheltering in Place Procedures. It was reported that, approximately sometime between 12/27/2021 and 12/29/2021, the facility could not provide electricity to the residents’ bedrooms due to a snowstorm. The facility has written in their Sheltering In Place Procedures the following statement: “In case of outage EVGV (Eskaton Village Grass Valley) has a generator that will power common areas, kitchen & hallways. EVGV has an emergency supply closet stocked with water, blankets, lanterns and batteries located in storage behind main elevator. The individual rooms will not have Heat/AC so we can open apartment doors to circulate air into each room. Residents will be asked to stay in their rooms and staff would perform regular well-being checks. Meals would be delivered to the room (in-room dining) as well as activities and engagement opportunities.” The Emergency Power Sources document states in part “Resident Hallways/Corridors will be powered with lights and central air. EVGV has three (3) portable battery powered generators sources on site.” (...) “Care staff will have previously identified those residents that require assistance with Portable Oxygen. These individuals will be directed to a designated area or staff will supply temporary power for this period of this event.” The Call System Failure or Power Outage document states “When power is out for an extended period of time and residents are unable to use our Call System (Arial) for help we need to immediately: Provide each resident with a whistle/bell. The whistles/bells are located with evacuation supplies. Care staff will implement wellness checks on each resident at a minimum of every hour.” ** Report continued on 9099-C ** Based on interviews conducted by the Department and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with ED and a copy of this report was provided to the facility. The signature of the ED on these forms acknowledges receipt of these documents. During the interview process, it was reported by staff that, due to the power outage, the residents did not have electrical lighting in their bedrooms. It was reported that lighting was in the hallway and that doors were left open to receive light from the hallways. It was stated that residents were provided with a small battery operated lantern for their bedroom. Staff reported that most activities of daily living for the residents were provided. It was also mentioned by the staff persons that resident call buttons were working and that they could use those in case a resident needed to contact a care provider. The regulations state that there shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. It was reported by staff persons that the facility did supply light to the residents’ bedrooms with lanterns. Overall, it could not be proven that the facility's Emergency Disaster Plan was not sufficient regarding facility not supplying light to residents’ bedrooms. Allegation: Facility did not have staff to serve meals to residents The facility has written in their Sheltering In Place Procedures the following statement: “In case of outage EVGV (Eskaton Village Grass Valley) has a generator that will power common areas, kitchen & hallways. EVGV has an emergency supply closet stocked with water, blankets, lanterns and batteries located in storage behind main elevator. The individual rooms will not have Heat/AC so we can open apartment doors to circulate air into each room. Residents will be asked to stay in their rooms and staff would perform regular well-being checks. Meals would be delivered to the room (in-room dining) as well as activities and engagement opportunities.” During the interview process, staff persons reported that the facility was short staffed, as some staff persons could not get to work due to the snowstorm. It was reported that the kitchen had electricity and was preparing and providing meals to residents. Staff indicated that, although they were short staffed, the staff were able to get meals to the residents. Some staff reported that some residents were able to make it to the dining room and other residents ate their meals in their bedrooms. ** Report continued on 9099-C ** It was reported by the administrative staff that it was felt that the residual heat coming from the hallways into the residents' open bedroom doors would suffice to heat the resident bedrooms. The regulations state that a comfortable temperature for the residents shall be maintained at all times and that the facility shall heat rooms that residents occupy to a minimum of 68-degrees F. During a significant power outage, it was reported that no one monitored the temperature in the residents’ bedrooms to ensure that the rooms were at a comfortable temperature and at a minimum of 68-degrees F. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. The ED’s signature on these forms acknowledges receipt of these documents. During the investigative process, the administrator, eight staff persons, the Local Long-Term Care Ombudsman (LTCO), and three residents were interviewed. Numerous documents were obtained for review and included the facility's Emergency and Disaster Plan, Disaster Plan Summary, Floor Plan, Emergency Procedures, Food Services/Emergency Disaster Plan, Emergency Contact Numbers, and Sheltering in Place Procedures. It was reported that, approximately sometime between 12/27/2021 and 12/29/2021, the facility could not provide electricity to the residents’ bedrooms due to a snowstorm. The facility has written in their Sheltering In Place Procedures the following statement: “In case of outage EVGV (Eskaton Village Grass Valley) has a generator that will power common areas, kitchen & hallways. EVGV has an emergency supply closet stocked with water, blankets, lanterns and batteries located in storage behind main elevator. The individual rooms will not have Heat/AC so we can open apartment doors to circulate air into each room. Residents will be asked to stay in their rooms and staff would perform regular well-being checks. Meals would be delivered to the room (in-room dining) as well as activities and engagement opportunities.” The Emergency Power Sources document states in part “Resident Hallways/Corridors will be powered with lights and central air. EVGV has three (3) portable battery powered generators sources on site.” (...) “Care staff will have previously identified those residents that require assistance with Portable Oxygen. These individuals will be directed to a designated area or staff will supply temporary power for this period of this event.” The Call System Failure or Power Outage document states “When power is out for an extended period of time and residents are unable to use our Call System (Arial) for help we need to immediately: Provide each resident with a whistle/bell. The whistles/bells are located with evacuation supplies. Care staff will implement wellness checks on each resident at a minimum of every hour.” During the interview process, it was reported by staff that some residents were cold due to not having heat directly in the residents' bedrooms. It was stated that blankets were provided to the residents in an effort to assist the residents with staying warm. ** Report continued on 9099-C **the state’s words, verbatim · CDSS document, Jun 16, 2022 · control 25-AS-20211229094428

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(1) · Plan of correction due date: Jul 8, 2022

87303(b)(1) Maintenance and Operation - (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68-degrees F, (20 degrees C). This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that resident bedrooms were at a comfortable temperature and at a minimum of 68-degrees F., which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 16, 2022

Plan of correction: ED will develop a plan in writing on how the facility will avoid the complaint allegation from reoccurring. ED will submit plan to the Department by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 5/4/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Executive Director (ED) Cameron Uhlir and Assistant Executive Director (AED) Sydney Lawson. LPA explained the purpose of the visit. Prior to initiating the annual inspection, 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 and LPA completed a facility risk assessment at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA toured the interior and exterior of the facility together with ED and AED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, one (1) bathrooms, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, May 4, 2022

Allegation investigated: ) Staff not providing meals to resident in a timely manner. 2) Staff not providing adequate food service for resident.

On 6/16/2021 at 3PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigation visit regarding the above allegation and Resident Care Coordinator II Monica Avalos. Prior to initiating the 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; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Additionally, LPA was screened by facility's automated temperature system and front desk personnel. Continuation on LIC 9099C. Substantiated 1) Staff not providing meals to resident in a timely manner. Based on 10 staff and 12 resident interview statements obtained, LPA determined that the above allegation occurred. Four staff members interviewed confirmed that there were incidents of residents receiving their meals late or not at all during October 2020. Two residents confirmed to have received their meals late during this period. 2) Staff not providing adequate food service for resident. Based on 10 staff and 12 resident interview statements obtained, LPA determined that the above allegation occurred. During this period, 4 staff members confirmed of burnt toast being served and 2 residents confirmed receiving burnt toast. 3 staff members did not visually witness burnt toast being served but doesn't doubt that that residents did receive burnt toast. 3 staff members confirmed that residents were served frozen or undercooked vegetables and 1 staff confirmed the allegation. Based on LPA information obtained during investigation, 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), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Jul 23, 2021 · control 27-AS-20201001113808

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 2, 2021

87464 Basic Services (f)(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on staff and resident interviews, Licensee did not provide meal services on time which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2021

Plan of correction: Licensee agrees to conduct an in-service training regarding facility meal service procedures and submit training materials along with food service staff to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Aug 2, 2021

87555 General Food Service Requirements (b)(8) All food shall be of good quality. This requirement was not met as evidenced by: Based on resident and staff interviews, Licensee did not ensure that fozen and/or undercooked food were not served to residents which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2021

Plan of correction: Licensee agreed to conduct an in-service refresher course regarding ServSafe Food Handling requirements and submit training materials along with signatures of food service staff to LPA by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA)s Williams and Keosavang arrived at the facility unannounced on 06/2/2021 to conduct a Required 1- Year Inspection utilizing the infection control domain. LPAs met with Administrator, Sean Beloud, and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs 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 and contacted licensee and completed a facility risk assessment. LPAs ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPAs was screened by facility staff upon entering the facility. LPAs and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, seven (7) resident bedrooms, numerous restrooms, kitchen, and courtyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jun 2, 2021