Cambridge House

Allegation investigated: Staff are not allowing family to visit resident

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by caregiver Irene Sheilds, and explained the reason for the visit. The department received a complaint on 08/01/2023 and the initial 10 day visit was conducted on 08/08/2023. LPA Mendivil obtained copies of physician report and admission agreement. LPA interviewed staff and a witness. Regarding the allegation the staff are not allowing family to visit resident, the investigation revealved the following: Based on conversations with Licensee/Administrator Evelyn Wallace, Administrator stated they have not denied anyone visitations. Administrator reported that they have allowed all residents to have visitors. Unfounded Based on conversations with a witness it was reported that they have been able to visit their relative, but was told by the facility to contact relative's Power of Attorney prior to visiting, but was not told they could not visit their relative. Therefore based on the preponderance of evidence through records reviewed and interviews conducted the allegation that Staff are not allowing family to visit resident is determined to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 17, 2023 · control 22-AS-20230801161429

Allegation investigated: Staff refuse resident to have visits

On this Day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Caregiver Ray Villanueva. Administrator Evelyn Wallace arrived shortly after. The department received a complaint on 04/25/2023 and initial 10 day visit was conducted on 4/28/2023. During the course of the investigation LPA Mendivil obtained copies of the following: admission agreement and house rules. Regarding the allegation staff refuse resident to have visits, the investigation revealed the following: Based on interviews with Administrator Evelyn Wallace the facility policy for visitation is to allow visitors from 9 am to 7pm with exceptions for end of life or hospice. Administrator Evelyn stated all residents and/or responsible parties have signed admission agreement and personal rights document, which outlines residents' personal rights to visitations. CONT on LIC 9099-C Substantiated Administrator acknowledges has not allowed a visitor for Resident 1 (R1) due to family has told the facility to not allow a specific visitor. Based on interviews with Administrator she does not have any court order document on file that would exclude visitors from visiting R1. LPA was unable to conduct interviews with residents as 2 residents did not wish to be interviewed and the remaining 2 were unable to be interviewed. Interview conducted with 1 resident indicated their family visits almost every day. Based on the preponderance of evidence through interviews and observations the allegation that Staff refuse resident to have visits is SUBSTANTIATED, meaning the complaint allegation was valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report and appeal rights was provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 28, 2023 · control 22-AS-20230425133150

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: May 4, 2023

a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidence by Administrator stated they have not let R1's family member visit on 2 occasions. This poses a risk to personal rights.the state’s words, verbatim · CDSS document, Apr 28, 2023

Plan of correction: Administrator will allow visitors and remind families of Title 22.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA)Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Caregiver Irene Shields and explained the reason for the visit. At 9:35 AM Administrator Evelyn Wallace arrived during the visit. At 9:10 AM, LPA toured the facility. Facility is 5 bedroom, 3 bathroom single story home with a detached garage. Facility has 5 residents present during today's visit. LPA observed residents relaxing in the facility and in their respective rooms. LPA Mendivil observed postural supports on 5 out of 7 beds. All residents rooms had the required elements as well as restrooms stocked with soap. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes residents temperatures daily and documents. The facility mitigation plan has been completed and approved. LPA observed emergency food and did not observe emergency water. LPA observed unsecured prescription medication in kitchen cabinet for new resident. LPA observed locked medication cabinet.LPA observed unlocked knives in a drawer in kitchen and unsecured cleaning supplies under sink and above washer and dryer. LPA toured the outside grounds and observed outside shaded visitation area. Exit gate is unlocked and self latching. Exit gate is blocked by trash cans and discarded furniture. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation .LPA observed one pack of masks for facility. LPA reviewed all residents files and all contained required documentation including updated emergency information. All staff and residents are vaccinated for Covid 19. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.the state’s words, verbatim · CDSS document, May 24, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA was greeted and granted entry by Caregiver Irene Shields. Administrator Evelyn Wallace arrived shortly after and the reason for the visit was explained. Upon entry LPA was was not screened per COVID guidelines. LPA began the tour of the facility. The facility currently has 4 residents in care. LPA observed all 4 residents relaxing, and/or watching TV one resident had a visitor. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility staff does not screen visitors. LPA observed the screening station in the entrance of the facility with only 2 bottles of hand sanitizer. Facility does not keep documentation in regard to COVID for all the visitors, staff, and resident. LPA observed hand washing guidelines posted in all bathrooms of facility. LPA observed facility has COVID precautionary posting throughout the facility as well as all required Department postings. Facility has an active COVID-19 prevention plan in place for the safety of residents in care. LPA observed ample of emergency food and water as well as First Aid kit in the facility. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place. LPA toured the outside and observed two tables with umbrellas that can be used for outdoor visitation. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation as needed. LPA provided Technical Assistance regarding routine symptom screening (temperature and symptom check), at entry for all staff, residents, and visitors, documenting daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents, and a sign-in policy for all visitors. Mitigation Plan was submitted and has been approved. Based on the observations made during today’s visit, no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator and a copy of this report, and LIC9102 were provided.the state’s words, verbatim · CDSS document, Jul 29, 2021

The state marks this report as 5 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.