Newport Beach Memory Care

Allegation investigated: One of the facility's routes of egress is in disrepair

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by the facility's Operations Manager before listing the allegation. LPA accompanied by Operations Manager toured the facility's physical plant and the exits leading away from the ground level's living units. All doors observed are equipped with a digital pad used to disable the sound alarm in place to alert staff of the exit being used. Signage indicating delayed egress systems being in use is also observed on exit doors. There are two routes of egress leading from the memory care area on the first level using a delayed egress. Both have been tested during the visit, with the bar being pushed for the required amount of time and the corresponding sound alarm being witnessed locally and at a central console. The facility staff was unaware of the test being conducted and the response observed was appropriate in terms of location and delay. CONTINUED ON LIC9099-C Unfounded CONTINUED FROM LIC9099-A LPA conducted or attempted a total of six staff interviews during the investigation visit. Regarding the allegation that an Inoperant alarm has allowed unsupervised exits from residents with dementia, the following has been concluded: Based on observation and interviews conducted, the sound alarms are functional and staff response is consistent with the prevention of wandering risks in the facility's residents. None of the staff members interviewed corroborated the occurrence of an incident during which any resident was able to exit the facility unsupervised. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 LPA conducted or attempted a total of six staff interviews during the investigation visit. Regarding the allegation that One of the facility's routes of egress is in disrepair, the following has been concluded: Based on the observation conducted during the tour of the physical plant, the delayed egress systems on both exit routes are operational. The gate only opens after a push on the bar for 15 seconds, immediately triggering an alarm at a central location alerting staff to the egress attempt. On both instances, facility staff was witnessed to intervene immediately to ensure no resident was able to exit the facility unsupervised. The exit gate between the secure outdoor space behind the facility and the parking was also confirmed to trigger a remote alarm but somehow did not sound locally. The allegation is therefore found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The Department has investigated this complaint. LPA provided a consultation on the regulatory requirements specific to dementia care documented in an attached Technical Assistance Advisory Note. Due to the presence of two large items in front of the backside egress gate, later easily repositioned away from the gate by facility staff, a Technical Violation Advisory Note regarding the requirements of the California Code of Regulations Section 87307(d)(6) was issued and a consultation provided to facility representative. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Aug 29, 2023 · control 22-AS-20230824164013

Allegation investigated: Facility administrator does not have proper qualifications

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation into the allegation listed above. LPA was greeted and granted entry by the facility's Operations Manager after stating the purpose of the visit. An initial investigation visit was conducted on August 14, 2023. Following the resignation of former Executive Director S1, the licensee has designated S2 as the new Operations Manager for the facility. At the time of the initial visit, S2 is confirmed to not be in possession of an active Administrator certificate. Documentation provided during the present follow-up investigation visit demonstrated that S1 was on payroll for the facility until August 15, 2023 included. Starting August 16, 2023, an interim supervising administrator (S3) was named and was confirmed by LPA to be in possession of an active administrator certificate. CONTINUED ON FORM LIC9099-C Unfounded CONTINUED FROM FORM LIC9099 Until Operations Manager S2 is able to complete the initial training to become a certified Residential Care Facility for the Elderly (RCFE) Administrator, it is stated that he will operate under the guidance and supervision of the current active certification holder. As a result of this investigation, the allegation that Facility administrator does not have proper qualifications is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The Department has investigated this complaint. A consultation on the requirements for the presence of a certified administrator was provided to the facility's representative through a Technical Assistance Advisory Note, in an attached form LIC9102 as a corroborated lapse in the presence of an administrator within twelve months of a previous citation for failure to comply with Section 87405(a) of the California Code of Regulations issued on March 6, 2023 would constitute a repeat violation associated with an immediate civil penalty in the amount of $250. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Aug 17, 2023 · control 22-AS-20230809163155

Allegation investigated: Staff does not have proper training to care for resident in care.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by the facility's Operations Manager before listing the allegation. LPA requested and reviewed records for resident R1. The physician report based on an examination dated February 9, 2023 indicates that resident is diagnosed with dementia and has a colostomy bag installed. Due to the dementia diagnosis, the resident is not mentally and physically capable of providing all routine care for the ostomy. Following the resident's admission on May 28, 2023, the ostomy was attended to by skilled professionals under an admission with Apex Home Health. Following an incident with one of the providers sent by Apex, the resident was discharged from the service after July 15, 2023 and before August 10, 2023. CONTINUED ON FORM LIC9099-C Unfounded CONTINUED FROM FROM LIC9099 After the Home Health discontinuation of care, supervision of the resident's ostomy was taken over by staff member S1 Wellness Director who was in possession of an active nursing license. After the former Executive Director was terminated, S1 submitted their resignation as well. At that time, the supervision of the ostomy was taken over by the facility's interim LVN on call from the Skilled Nursing Facility operated by the same licensed entity and located across from Newport Beach Memory Care. Documentation of the interim LVN's endorsement was provided to LPA during the visit, in addition with email exchanges with the resident's care manager. A physician order for the admission of the resident into Hoag Home Health was obtained on August 15, 2023 and submitted to the provider on the same day. The ostomy bag was also observed to be clean and was replaced on August 15, 2023. The investigation confirmed continuity in the routine care of R1's ostomy bag by skilled professionals as required by the California Code of Regulations Section 87621. As a result, the allegation that Staff does not have proper training to care for resident in care is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The Department has investigated this complaint. A consultation on the requirements for the admission of residents with Restricted Health Conditions was provided to the facility's representative through a Technical Assistance Advisory Note, in an attached form LIC9102. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Aug 17, 2023 · control 22-AS-20230814133520

Allegation investigated: Facility is refusing to disclose information regarding the incident Facility did not report a fall that occurred to a resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Director Michele Goodney and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report and facility notes. Regarding the allegations that facility is refusing to disclose information regarding the incident and facility did not report a fall that occurred to a resident, the investigation revealed the following: On 10/06/2021, Resident 1 (R1) was observed to have an abrasion on right eye and complained of hip and leg pain. Facility notified responsible party of bruise and hip pain and physician ordered mobile X-ray per responsible party. Results of X-ray on 10/07/2021 indicated a right hip fracture and resident was sent out to Hoag Hospital. Facility staff deny witnessing any fall and facility states being unsure how the injury occurred. Facility provided an incident report to the department on 10/13/2021. Facility documentation dated 10/06/2021 indicated it was unknown if a fall had occurred and that responsible party and physician CONT ON LIC 9099C DATED 08/01/2023. Unsubstantiated were notified of the incident at 8:30 AM on 10/06/2021. Responsible party confirms being notified of the resident's pain and bruising. Facility indicated resident was equipped with a clip alarm as well as a lowered bed and was observed frequently. Due to conflicting information, the department is unable to corroborate the allegations. Therefore, the allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided and left at the facility.the state’s words, verbatim · CDSS document, Aug 1, 2023 · control 22-AS-20220223160724

Allegation investigated: / Staff do not maintain a comfortable temperature for residents in care. 3/ Staff did not ensure that resident was provided their medication in a timely manner. 5/ Staff do not ensure that residents are provided with activities while in care.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of delivering findings in the investigation of the allegations listed above. LPA was greeted and granted entry by administrator Michelle Goodney after explaining the purpose of the visit and listing the allegations. An initial visit was conducted on February 3, 2023. A tour of the physical plant was conducted with the administrator, and temperature measurements were taken. A sample of staff training records were reviewed. Staff schedules reviewed. Previous temperature measurements were taken during facility visits on January 4 and January 17, 2023. Seven additional staff interviews were conducted during an investigation visit for complaint reference #22-AS-20221228101134 on March 6, 2023. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 A follow-up visit was conducted on this day, during which the Maintenance Director was interviewed and Medication Administration Records were reviewed. Regarding the allegation that Staff do not maintain a comfortable temperature for residents in care, the following has been concluded: After a similar allegation was made as part of complaint 22-AS-20221228101134 filed on December 28, 2022, temperature measurements were taken during multiple facility visits on January 4, January 17 and February 3, 2023 as well as during today's visit. Facility received a citation in regard to the faulty heating units. Based on following observations and interviews conducted, there was not sufficient evidence to confirm that the issue was still ongoing. As a result, the allegation is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation that Staff did not ensure that resident was provided their medication in a timely manner, the following has been concluded: LPA observed MedTech staff while touring the facility and reviewed print-outs of the Medication Administration Records for the months of March and April for a random sample of five residents out of 20 currently present within the facility. All daily doses are observed to have been administered correctly and typed into the system adequately. The allegation is therefore deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation that Staff do not ensure that residents are provided with activities while in care, the following has been concluded: During the initial visit, facility staff was observed wrapping up activities as listed and residents resting. Further interviews with the facility's Activities Director confirmed that activities were being offered to residents on each weekdays when Director is present, but that was not generally the case on weekends due to the responsible staff member not being scheduled on those days and care staff not having the availability to pitch in significantly. Administrator states that more dedicated staff may be hired if and when facility census gets higher. Therefore, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was reviewed and left to facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff are not sufficiently trained, the following has been concluded: Based on a review of a random sample of staff records reviewed during the initial investigation visit on February 3, 2023, all applicable training was found to have been adequately received and documented. A limited number of shifts are covered by Registry staff with potentially less knowledge of the facility's residents, however the placement agency is also responsible for ensuring that their provided staff have received the required training. Therefore, the allegation is found to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was reviewed and left to facility representative. CONTINUED FROM FORM LIC9099-A LPA additionally reviewed two Special Incident Reports submitted by the facility to the Department on March 17, 2023 and March 21, 2023 regarding two fall incidents that occurred during the use of the recliner seats with the legs in the upward position. A follow-up visit was conducted on this day, during which the Maintenance Director was interviewed and Medication Administration Records were reviewed. Regarding the allegation that Staff are restraining residents while in care, the following has been concluded: Based on interviews conducted and observations made during three separate tours of the physical plant, recliners were confirmed to have been in use in the upward position during each of the visits. Even though residents did not appear to exhibit signs of distress at the time, the Department later received two incident reports linked to fall incidents that occurred while the recliners were up and residents with limited mobility or impaired cognition were not able to exit the seats safely without staff assistance. As a result, the allegation that Staff are restraining residents while in care is deemed to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B citation is issued regarding the deficiency substantiated during the investigation. An exit interview was conducted and a copy of this report along with appeal rights were reviewed and left at the facility.the state’s words, verbatim · CDSS document, Apr 14, 2023 · control 22-AS-20230131162326

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(2) · Plan of correction due date: May 12, 2023

The California Code of Regulations Section 87608(a)(2) states that: "Postural supports shall be fastened or tied in a manner that permits quick release by the resident." This requirement is not met as evidenced by: On multiple documented instances, residents were found to be unable to bring (...) (...) the legs of the recliner seat down, contributing to a fall incident. This constitutes a potential risk to the health, safety and personal rights of the individuals in care.the state’s words, verbatim · CDSS document, Apr 14, 2023

Plan of correction: Licensee to provide in-service training to care staff regarding the safe use of the recliners with an emphasis making sure to not impeded a resident's personal right to ambulate and safely ensuring the residents' ability to exit the recliner if it is put up. Documentation of the training to be provided before POC due date

Allegation investigated: Staff are unable to communicate due to language barrier

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to deliver findings into the investigation of the allegation listed above. LPA was greeted and granted entry by facility staff. Administrator Michelle Goodney was notified of the visit and arrived later to assist. An initial visit was conducted on March 6, 2023. Staff schedule reviewed, staff interviews conducted. Based on documents reviewed and staff interviews, staff member S1 was confirmed to be present on the day reported in the initial complaint report. S1 was confirmed by interview to be fluent in English. The allegation is therefore Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was reviewed and left to facility representative. Unfoundedthe state’s words, verbatim · CDSS document, Apr 14, 2023 · control 22-AS-20230227164107

Allegation investigated: / Facility heater units are in disrepair 3/ Facility is operating without an Administrator

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegatons listed above as well as to deliver findings to the licensee. An initial investigation visit was conducted at the facility on January 4, 2023. A tour of the physical plant was conducted with the administrator and a sample of units on both floors were observed. The room's individual thermostats and HVAC units were tested. Records were requested and reviewed, including the resident census, LIC500 Personnel Report (LIC500), staff schedule for a two-week period starting on November 27, 2022, staff payroll records and a sample of six resident files on record. A type B violation was documented as part of a case management visit the same day. LPA conducted a follow up visit on January 17, 2023 after additional concerns regarding staffing were brought to the attention of the Department. (CONTINUED ON FORM LIC9099-C) Substantiated (CONTINUED FROM FORM LIC9099) During the visit, LPA toured the two levels of the facility again and observed staffing levels to be in accordance with documented staffing goals for the facility. Records reviewed included past schedules which demonstrated adequate staff coverage for the three daily shifts. An additional tour of the physical plant was conducted on February 3, 2023 as part the complaint investigation referenced 22-AS-20230131162326. HVAC units were all observed to be functional at that point and temperatures were observed. A final facility visit was conducted on March 6, 2023. A tour of the physical plant was conducted and eight staff interviews were conducted by LPA during the visit. Regarding the allegation that Facility heater units are in disrepair, the following was concluded: At some time towards the end of Summer 2022 and the beginning of Winter 2022, multiple staff stated in interviews that individual heater units were dysfunctional and were temporarily replaced by electric floor heaters that had been ordered by the previous leadership team. Upon conducting the initial inspection visit, LPA was informed by the new leadership team that repairs were under way and have now been completed. Individual units are observed to be functional at the time of the present visit. A majority of accounts confirmed the statement, therefore the allegation is deemed to be Substantiated, meaning the preponderance of evidence standard has been met. Regarding the allegation that Facility is operating without an Administrator, the following was concluded: Around Thanksgiving 2022, the former executive director held an all-hand meeting to informally announce to staff the possibility that she might leave the facility. Over the following weeks, both the Executive Director and the previous Wellness Director became increasinly prone to being absent from the facility without HR or front desk staff being informed. No official notice of a last day at the facility or notice of delegated administrator responsibilities were issued by the licensee, leaving facility staff to improvise procedures to keep major facility functions operational. This lasted for several weeks until the current administrator was hired and onboarded on December 19, 2022. A majority of accounts confirmed this version of events, therefore the allegation is deemed to be Substantiated, meaning the preponderance of evidence standard has been met. Two citations were issued on an attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to facility representative. During the visit, LPA toured the two levels of the facility again and observed staffing levels to be in accordance with documented staffing goals for the facility. Records reviewed included past schedules which demonstrated adequate staff coverage for the three daily shifts. An additional tour of the physical plant was conducted on February 3, 2023 as part the complaint investigation referenced 22-AS-20230131162326. A final facility visit was conducted on March 6, 2023. A tour of the physical plant was conducted and eight staff interviews were conducted by LPA during the visit. Regarding the allegation that Staff are insufficient in numbers to meet resident needs, the following has been concluded: Starting with the leadership team transition period in November/December and disruption in the chain of communication for staff calling out, difficulties with staffing occurring more often, causing staff to have to stay on overtime to ensure coverage goals were met. Additional hires were implemented to progressively remedy the amount of private agency staff the facility had to rely on. Multiple reviews of clock-ins and schedules demonstrated that the minimum targeted amount of staff were present at the facility. The allegation is therefore found to be Unsubstantiated, meaning 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. An exit interview was conducted and a copy of this report was provided and left at the facility.the state’s words, verbatim · CDSS document, Mar 6, 2023 · control 22-AS-20221228101134

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Mar 6, 2023

The California Code of Regulations Section 87405(a) Administrator - Qualifications and Duties states that: "(...) When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible." This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, when the former Administrator's resignation, no official designation of responsibility was made. This deficiency posed a potential risk to the health, safety and personal rights of individuals in carethe state’s words, verbatim · CDSS document, Mar 6, 2023

Plan of correction: A replacement administrator was hired and started employment on December 19, 2023. However, licensee will make sure that a qualified administrator is designated for coverage should another instance of prolonged absence occur.

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

The California Code of Regulations Section 87303(a) on Maintenance and Operation states that: "The facility shall be (...) in good repair at all times." This requirement was not met as evidenced by: Based on interviews conducted, an unspecified number of individual heating units were stated to have been non-functional, causing the previous administrator to provide heat by means of unauthorized floor heating units that were later removed before heating was repaired. This deficiency posed a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Mar 6, 2023

Plan of correction: At the time the Substantiated findings were delivered, facility had already completed the required repairs and the entire facility was observed to be in compliance with mandated temperatures. The Plan of Corrections is considered to be cleared at this time.

Type of visit: Case Management - Other

On this day, Licensing Program Analyst (LPA) made an unannounced visit to the facility for the purpose of delivering an amended form LIC9099 for a complaint investigation 22-AS-20230131162326 conducted on February 3, 2023. LPA was greeted and granted entry by Administrator Michele Goodney. The original facility visit report was marked as concluded the allegations as unsubstantiated, while the narrative of the report and exit interview conducted considered the allegations as requiring further investigation. The report was amended to reflect the correct status for the ongoing investigation. Exit interview conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 6, 2023

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a case management inspection. LPA met with administrator Michele Goodney and explained the purpose of the visit. A review of the resident records on file within the facility was conducted on a sample of residents R1, R2, R3, R4, R5 and R6. The entire records for resident R6 are absent from the facility after a family member requested the file for the purpose of a separate litigation. The previous administrator provided the family with the original file and has not recovered the file before leaving her position. At this time, the file has not been returned to the facility. The physician report for resident R5 who was recently admitted to the facility is absent from the file also. Based on the review of records conducted at the facility, one deficiency is being cited under Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights was provided and left at facility.the state’s words, verbatim · CDSS document, Jan 4, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 3, 2023

The California Code of Regulations Section 87506(a) on Resident Records states that: "The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility (...) readily available to facility staff and to licensing agency staff." This requirement is not met as evidenced by the missing file observed for resident R6. This deficiency poses a potential risk to the health, safety and personal rights of the individuals in care.the state’s words, verbatim · CDSS document, Jan 4, 2023

Plan of correction: Licensee will ensure that a separate, complete and current record is being maintained at the facility for each individual in care at the facility before the Plan of Corrections due date.

Type of visit: Case Management - Other

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering an amended complaint investigation report (LIC9099-A) regarding the complaint referenced 22-AS-20221003102027. LPA was greeted and granted entry by Chanel Sanchez, Executive Director after explaining the purpose of the visit. Copies of the signed amended report and this facility visit report were printed and left at facility. Exit interview provided to facility representative.the state’s words, verbatim · CDSS document, Oct 25, 2022

Allegation investigated: Facility did not provide authorized representative with refund.

This report was amended. Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required complaint investigation. LPA arrived at facility, was greeted and granted entry by Chanel Sanchez, Executive Director after explaining the purpose of the visit and detailing the allegation investigated. LPA requested and obtained the facility census, as well as an admission packet designed for prospective residents including a blank admission agreement which includes a provision regarding the facility refund procedure in the event of a resident's death. Agreement indicates that refund will be issued "within fifteen (15) days after (...) personal property is removed from the facility". LPA also requested copies of the records kept at the facility for resident 1 (R1). Records were obtained during the visit and include the resident's signed admission agreement. Facility staff is unable to provide any documentation of a processed refund at the time of the visit. CONTINUED ON FORM LIC9099-D Substantiated CONTINUED FROM FORM LIC9099 LPA interviewed administrator Chanel Sanchez and Yvonne Laumasima, staff member in charge of facility payroll and accounts payable. Both staff members described the typical procedure for the pro-rating and refunding of fees, however both indicate that the previous administrator did not follow the procedure and no documentation exists. Additionally, the facility is transitioning their administrative service providers. No request for a refund has been submitted to accounts payable or the clearinghouse in charge of issuing the funds at this time. During the visit, facility staff generated an invoice for the refund and worked towards getting the refund submitted to the appropriate agency. Based on LPA’s information gathered through staff and witnesses interviews and review of records and staff admission statement that a refund has yet to be issued, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. An attached form LIC9099D is generated for the cited deficiency.the state’s words, verbatim · CDSS document, Oct 5, 2022 · control 22-AS-20221003102027

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Nov 7, 2022

The California Code of Regulations Section 87507(f) regarding Admission Agreements indicates that : "The licensee shall comply with all applicable terms and conditions set forth in the admission agreement(...)" This requirement is not met as evidenced by: Based on observation, file review and interviews conducted, no refund has been issued in excess of the 15-day agreement upon admission. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 5, 2022

Plan of correction: Licensee will provide documentation of the submission and effective payment of the refund to Licensing Program Analyst before the Plan of Corrections due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety case management visit. LPA was greeted and granted entry into the facility by Wellness Director Alex Gutierrez and explained the reason for the visit. During the visit, LPA toured the facility and observed the following: Facility is following covid screening guidelines and LPA observed the screening/ sanitizing station. Residents were observed relaxing in the common areas of the facility and appeared safe and well taken care of. Facility had two covid cases starting on 07/15/2022. Cases were not reported to Licensing or Public Health and department learned of cases through an outside source. Cases were reported to Licensing on 07/21/2022 after LPA made contact with facility. LPA consulted with Wellness Director regarding the importance of all staff wearing masks at all times per department guidance. Based on the observations made during today's visit, deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview conducted and a copy of the appeal rights were given at time of visit.the state’s words, verbatim · CDSS document, Jul 28, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Jul 29, 2022

Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following: Occurrences, such as epidemic outbreaks.. which threaten the welfare, safety or health of residents.., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. Based on interviews conducted, Licensee failed to ensure covid cases were reported to Licensing or Public Health. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Licensee to forward a statement of understanding regarding reporting requirements and forward to LPA by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 04/12/2022. LPA was greeted and granted entry into the facility by Administrator Chanel Sanchez and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 1569.695(f)(1) pertaining to Emergency Water has been cleared. Licensee obtained emergency water. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87468.2(a)(2) pertaining to Medical Assessments has been cleared. Licensee obtained updated physician reports. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 1569.695(f)(1) pertaining to Evacuation Chairs has been cleared. Licensee obtained evacuation chairs. Licensee has complied with the terms of the POC. Advisory note dated 04/12/2022 indicated the following item to be addressed: Facility is not screening staff or visitors. LPA was not screened upon entry. Based on the observations made during today's visit, deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview conducted and a copy of the appeal rights were given at time of visit.the state’s words, verbatim · CDSS document, May 18, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 25, 2022

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by: Based on observation, Licensee is not screening visitors to the facility. Facility was given an advisory on 04/12/2022 to begin screening visitors. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 18, 2022

Plan of correction: Licensee agrees to screen all who enter the facility and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Chanel Sanchez has an administrator certificate expiring on 07/06/2023. At 9:56 AM, LPA toured the facility with Administrator Chanel Sanchez. Facility has 22 residents in care during today's visit with 7 residents on hospice care. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements. Facility utilizes a hand written visitor sign in sheet. Facility takes resident temperatures daily and documents. LPA observed the first aid kit has all required items including tweezers and scissors. LPA observed sufficient supply of emergency food as well as emergency supplies. Facility does not have emergency water in place. LPA observed multiple shaded outside visitation areas. Facility is approved for delayed egress. Facility contracts an outside agency, Fire Safety First, for fire sprinkler and smoke detector safety. Last visit was on 08/16/2021. At 10:20 AM, LPA observed all three stairwells do not have an evacuation chair. LPA observed the locked medication room. Facility utilizes an electronic medication administration record. Facility provides activities in the form of exercise and games. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and all files have updated emergency information. LPA observed two out of three residents with Dementia do not have an updated physician report. During the visit, LPA consulted with Administrator regarding the importance of taking staff temperatures daily and documenting. Additionally, LPA advised on the importance of hand washing signs in all common restrooms. Based on the observations made during today's visit, deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview conducted and a copy of the appeal rights were given at time of visit.the state’s words, verbatim · CDSS document, Apr 12, 2022