Iris Guest Home

Allegation investigated: Staff is not meeting resident's needs. Facility is malodorous.

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 Jean Vera Cruz, caregiver and explained the reason for the visit. Licensee/Administrator Brevet Dao arrived at 10:40 am. The department received a complaint on 07/21/2023 and LPA Cho conducted the initial 10 day visit on 07/28/2023. During the course of the investigation LPA Cho interviewed staff and residents. LPA Mendivil obtained copies of apprasials/needs and services plans. Regarding the allegations that Staff is not meeting resident's needs and facility is malodorous, the investigation revealed the following: LPA Mendivil reviewed 4 out of 4 residents files. Per review 4 out of 4 Appraisal/Needs and Services Plan did not provide actionable objectives/plans. Review of Resident 1 (R1) Appraisal/Needs and Services Plan dated 12/01/2022 indicating R1’s diagnosed with Parkinson’s Disease, atrial fibrillation, hypertension, bipolar, mild cognitive impairment, depression, and unsteady gait. CONT on LIC 9099-C Substantiated For the category of Physical/Health it is noted that “because of Parkinson’s affecting him, his physical mobility has been affected” it was noted that Physical Therapist (PT) and Occupational Therapist (OT) would be responsible for this need. Based on interviews with Administrator as of the date 12/02/2022 no PT/OT has seen R1. Review of Resident 2 (R2) Appraisal/Needs and Services Plan dated 01/14/2023 indicating R2 is diagnosed with depression, psychosis, and dementia. In the category of Emotional Needs, it is noted “he is able to adjust emotionally and no issues”. For the objective/plan for the emotional need the objective is “to continue to monitor”, per review there is no actionable item to monitor. Based on LPA’s observations of R2, R2 remains in his room and does not socialize with house mates. Review of Resident 3 (R3) Appraisal/Need and Services Plan dated 04/14/2023 indicating R3 is diagnosed with dementia, hypertension, and glaucoma. It is also noted that R3 needs assistance with all activities of daily living. In the category for Functioning Skills, it is noted "due to generalized weakness overall body function is affected", for the objective/plan "encourage to mobilize extremities, perform exercises on both hands and feet" the care team is responsible for this action. Based on interviews with witnesses, PT has been utilized but care giving staff has not. Review of Resident 4 (R4) Appraisal/Need and Services Plan dated 06/02/2023 indicating R4 is diagnosed with wernickie's encephalopathy and dementia. Per review of all five category's did not list any services for a diagnosis of dementia. Regarding the facility being malodorous LPA Mendivil experienced a strong smell of body odor and urine when entering the room of R1 and R3 on multiple occasions, no explanation provided from staff. Therefore, based on evidence through records reviewed and interviews the allegations that Staff is not meeting resident's needs and facility is malodorous are determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. Civil penalty is assessed due to repeat violation within 12 months. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 22-AS-20230721153400

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(a) · Plan of correction due date: Oct 23, 2023

(a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care... This requirement was not met as evidence by in 4 out of 4 residents needs and services did not provide actionable items to assist residents in any given category. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Licensee to update resident needs and services. Licensee stated will keep records of actions taken and outcomes daily.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 23, 2023

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidence by LPA Mendivil experienced a strong body odor and urine smell from R1 & R3's room. This poses a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Licensee has a cleaning schedule and as of 10/17/2023, the facility no longer is malodorous.

Allegation investigated: facility does not maintain a healthful and comfortable accommodations for residents Facility water temperature is not within regulatory temperature range

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into facility by caregiver Jean Vera Cruz and explained the reason for the visit. Administrator Brevet Dao was notified of LPA’s arrival and joined approximately at 10:40am. The Department received a complaint on 05/11/2023 and conducted the initial visit on 05/19/2023. LPA Mendivil obtained copies of pertinent documents including but not limited to: physician orders. In regards to the allegations Facility does not maintain a healthful and comfortable accommodations for residents and Facility water temperature is not within regulatory temperature range the investigation revealed the following: Regarding the allegation facility does not maintain a healthful and comfortable accommodations for residents, it was alleged Resident 1 (R1) was left in soiled clothing. Per physician report dated 12/14/2021 R1 is able to dress and groom self and is able to communicate needs. R1 is noted to have a diagnosis of Depression, Bipolar disorder and Parkinson’s disease. Unsubstantiated During LPAs visit on 5/19/23 LPA Mendivil observed R1 to have stained clothing and noted a strong body odor coming from R1. Per records reviewed, R1 needs and service plan dated 12/1/22 does not address and/or note any issues with R1’s refusal and/or inability to self care for grooming needs. Per interviews conducted with facility staff, R1 will refuse to provide staff with their laundry at times. Staff reported doing laundry at minimum twice a week for residents in care and sometimes more, depending on how much laundry there is to wash. Interviews conducted with 4 of 4 residents could not corroborate the allegation. R1 reported their laundry is clean after staff wash their clothes and reported they have enough clean clothing. Although R1 at times will refuse to participate in meeting own hygiene needs, it does not appear that the facility did not maintain a healthful and comfortable accommodations for residents. Therefore, based on preponderance of evidence, the allegation has been determined to be Unsubstantiated meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. It was alleged the facility water temperature is not within regulatory temperature range. During LPA’s visit dated 09/26/2023 LPA tested hot water temperature in bathroom 1 and observed the hot water to be 110 degrees F. Facility does not maintain a hot water temperature log. Per interviews with residents, residents reported the water to be ice cold. Staff denied knowledge of issues regarding hot water. Therefore, based on preponderance of evidence, the allegations has been determined to be Unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. An exit interview was conducted with Administrator and a copy of this report was provided at the time of exit. During LPA’s initial visit, no residents were observed to have full bedrails. Therefore, based on the preponderance of evidence gathered, We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit was conducted and a copy of this report was provided to facility representative. It was alleged the Facility is using half bed rails without physician orders. During the investigation, LPA observed Resident 2 (R2) to have half bed rails. Upon review of R2’s physician orders, no order could be found for half bedrails. LPA further observed Resident 3 (R3) to have half bedrails. Upon review of R3’s file, R3 was observed to have physician orders on file for half rails. During LPA’s initial visit, no residents were observed to have full bedrails. Therefore, based on the preponderance of evidence gathered, the allegations that Facility is using half bed rails without physicians orders and Facility's shower drain is in disrepair are determined to be Substantiated. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Administrator and a copy of this report, LIC9099-D, and appeal rights was provided at the time of exit.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 22-AS-20230511091058

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Oct 18, 2023

87608(a)(3) (a) Postural Supports. Based on the individual's preadmission appraisal, and subsequent changes to that appraisal,...(3) A written order from the physician indicating the need for the postural support shall be maintained in the resident's record. This requirement was not as evidence by R2 did not have physician's orders for half bed rails. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Licensee previously removed R2's bedrails and currenlty R2 is no longer at the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 23, 2023

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by LPA observed drain in bathroom 1 to have pooling when water was ran. This poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Licensee corrected issue after visit on 05/19/2023.

Allegation investigated: Administrator is evicting residents without a written notice

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 Ben Briones and explained the reason for the visit. The department received a complaint on 09/20/2023 and LPA Mendivil conducted the initial 10 day visit on 09/21/2023. During the course of the visit LPA Mendivil interviewed staff, residents and a witness. Regarding the allegation administrator is evicting residents without a written notice, the investigation revealed the following: Based on interivews with residents 2 out of 3 residents stated they were told on the morning of 09/20/2023 that they were going to be evicted and needed to relocate due to renovations. Interviews with 2 out 3 residents indicated they were offered a room at another licensed facility and were given 1 day to decide if they wanted to move to the other licensed facility. CONT on LIC 9099-C dated 09/21/2023 Substantiated Based on interviews with 2 out 3 residents indicated after they contacted their advocates the administrator provided an eviction notice around 6pm on 09/20/2023. Based on interviewers with residents 1 resident was not given the eviction notice and instead it was placed inside of the locked medicine cabinet and had to ask for the caregiver to provide the form. The 3rd resident would not answer LPA Mendivil's questions. Based on interviews with witnesses indicate the residents told them they felt like they were being evicted and given no option but to move the other licensed facility. Per interviews with Administrator Brevet Dao, Administrator Dao stated she did not give residents an ultimatum to move to another facility, but felt that she was providing residents with options. Administrator Dao stated she did not provide the written notices until after residents were informed verbally. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation Administrator is evicting residents without a written notice is SUBSTANTIATED, meaning the complaint allegation is 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 facility representative.the state’s words, verbatim · CDSS document, Sep 21, 2023 · control 22-AS-20230920162715

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(5)(A) · Plan of correction due date: Oct 2, 2023

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). ... (5) Change of use of the facility. A) The licensee may, upon no less than sixty (60) days written notice... ... evict a resident due to change of use of the facility. This requirement was not met as evidence by Administrator verbally told residents they needed to relocate due to eviction. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 21, 2023

Plan of correction: Licensee provided written eviction notice to residents.

Allegation investigated: Facility denied visitors

On this day Licensing Program Analysts (LPAs) Andrea Mendivil and Rosie Quiroz made an unannounced visit to conduct a complaint investigation. LPA Mendivil and LPA Quiroz were greeted granted entry into the facility by caregiver Ben Briones and explained the reason for the visit. Administrator Brevet Dao was available by phone. The department received a complaint on 08/08/2023. During the course of the investigation LPA Mendivil inteviewed staff and obtained copies of documents such as admission agreement. Regarding the allegation faciltiy denied visitors, the investigation revealed the following: Based on review of facility's admission agreement visitation hours are from 9am-7pm and admission agreement states "should other visiting times be needed, please contact the facility in advance to make arrangements". CONT on LIC 9099-C dated 08/15/2023. Unsubstantiated Based on interview with facility staff there was not been a time they have denied access to visitations. It was reported by witnesses that the facility did not allow visitations at 7:45pm and facility was called and no one responded to the door bell or phone. Interview with witness stated they did not call prior to 7:45pm to arrange a late visitation. Interviews with staff indicate they do not remember an instance when they did not answer the phone or the door. Therefore based on a preponderance of evidence through interviews and records reviewed the allegation facility denied visitors is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 15, 2023 · control 22-AS-20230808134542

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Joseph Alejandre and Dwayne Mason made an unannounced case management visit (See complaint #22-AS-20230721153400 dated 7/21/23). Earlier in the day, an attempted visit was initiated earlier this morning by Department personnel which had to be ended due to safety concerns. LPAs Mason and Alejandre conducted a Health and Safety visit at the facility to ensure the safety of the residents and staff and to retrieve State equipment. LPAs were greeted and granted entry by staff and explained the reason for the visit. LPAs along with staff toured the facility and reviewed resident medications and records. LPAs observed all residents were asleep at the time of the visit. LPAs observed both resident bathrooms were clean and operational. LPA observed a 7 day non-perishable and 2 day perishable food supply on hand. LPAs observed the facility had electricity, gas and water service. During the visit the facility temperature was 79.8 degrees Fahrenheit. LPAs observed a rodent caught in a trap in the water heater closet next to the bathroom. LPAs reviewed R1's medication records. R1 was prescribed Metformin 1000 mg twice a day, Simvastin 20 mg once a day, One-Daily Multivitamin one tablet a day, and Lisinopril 10 mg once a day. A review of R1's medication administration record shows R1 was not administered any medication on June 30, 2023. LPAs observed the kitchen was clean and organized. LPAs observed the see something say something poster (PUB 475) posted in the hallway. LPAs observed the fireplace in the living room is screened. LPAs observed water leaking from a drain pipe on the outside walkway leading to the back exit gate. LPAs observed next to the back exit gate, adjacent to the garage an old chair, nightstand and a dresser. LPAs observed the cleaning supplies are kept locked under the sink. LPAs observed the knives and sharp objects are kept locked in the caregiver's room. Based on the observations made during today's visit deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and a civil penalty is being issued for a repeat violation within a 12 month period. An exit interview was conducted and a copy of the report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Jul 28, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 29, 2023

The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not being met as evidenced by, LPAs observed a dead rodent caught in a trap in the water heater closet. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2023

Plan of correction: Licensee agrees to have a professional exterminator service the facility to eliminate the rodent issue. Licensee to forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(16) · Plan of correction due date: Jul 29, 2023

To receive or reject medical care or other services. This requirement is not being met as evidenced by, a review of the medication administration record shows R1 did not receive their prescribed medications, Metformin, Simvastatin, Lisinopril and One-Daily Multivitamin on June 30, 2023. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2023

Plan of correction: Licensee agrees to ensure all residents received medication as prescribed and to document all medication administered. Licensee agrees to train staff in regards to residents rights and medication administration. Licensee to submit proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced case management visit in conjunction with complaint visit . LPA met with Staff Ben Briones and explained the reason for the visit. LPA Mendivil arrived at the facility at 8:00 am for a complaint visit. LPA knocked on the door and rang the door bell for approximately 5 minutes without any answer. The facility is located on a lot with two separate properties. The two operate as separate facilities on the same property. Staff left the facility located in the front of the property unattended to go to the facility located to back of the property. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 11, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87467 · Plan of correction due date: Jul 12, 2023

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidence by; facility staff was not present when LPA arrived. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 11, 2023

Plan of correction: Licensee stated will conduct another in-service. Licensee will update LIC 500 and provide a copy to CCLD by 07/11/2023 COB.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of citing deficiencies. LPA met with Staff Ben Briones and explained the reason for the visit. On today’s date, Investigation Bureau (IB) conducted a follow-up visit at the facility and knocked at the door for about 15 minutes before a resident answered. The property the facility is located on has a front and back house. The two operate as separate facilities on the same property. Staff left the facility located in the front of the property unattended to go to the facility located to back of the property. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Jul 7, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464 · Plan of correction due date: Jul 8, 2023

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by; Facility resident answered the door for IB due to staff leaving the facility unattended to go to another facility located in the back of the same property.the state’s words, verbatim · CDSS document, Jul 7, 2023

Plan of correction: Staff Briones stated that they stepped to the back facility because that is where resident food is prepared and then brought to front facility. Staff Briones stated they will coordinate with other facility to have food brought rather then stepping away to retrieve it to ensure there is always supervison. An in-service is going to be held to ensure staff is coordinating so that there is always care and supervision of the residents.

Allegation investigated: Staff did not seek medical care for resident in care

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 Ben Briones and explained the reason for the visit. The deparmtnet received a complaint on 04/14/2023 and the department conducted the initial 10 day visit on 04/20/2023. During the course of the investigation LPA Mendivil interviewed staff and resident and obtained copies of pertinent documents such as physician reports. Regarding the allegation staff did not seek medical care for resident in care. Based on witnesses accounts Resident 1 (R1) fell sometime in the PM hours and R1 was on the floor. It was reported that staff was called into R1's room and picked up R1 and placed R1 back into bed. Per review of R1's physicians report dated 01/22/2022 does not indicate R1 is a fall risk. Unsubstantiated Based on witness' statements a physical therapist conducted an assessment on 03/30/2023 and R1 did not complain of pain and did not exhibit pain behaviors. Based on witness statements another assessment was conducted on 04/10/2023 a complete head to toe assessment and did not observe any indications of pain or injury. R1 was unable to be interviewed as R1 would not answer LPA Mendivil's questions. The facility staff was unable to confirm if R1 fell on 4/5/2023. Staff reported that if a resident was to fall and complain of pain they would call 911. Staff reported that in this case R1 did not complain of pain in the following days. Due to conflicting information from facility and witnesses it cannot be ascertained whether or not the facility did not seek medical care. Therefore based on the preponderance of evidence through record review and interviews the allegation that Staff did not seek medical care for resident in care is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided It was reported that R2 had to go to the hospital and did not return to the facility upon discharge. A report was never received for the incident with R2. Based on interviews with Administrator Brevet Dao Unusual/Serious Injury Report (LIC 624) form was not sent for the incident of R2. Though there is a dispute of a fall occurring with R1, the facility has not followed reporting requirements in a separate incident with R2. Therefore based on preponderance of evidence through record review and interviews the allegation Staff did not follow proper reporting requirements is determined to be SUBSTANTIATED, meaning the complaint allegation is 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 facility representative.the state’s words, verbatim · CDSS document, Jun 20, 2023 · control 22-AS-20230414130816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 26, 2023

87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following…A written report…Any incident which threatens the welfare, safety or CONTINUED.. health of any resident…This requirement is not met as evidence by: Licensee failed to submit a written report to CCLD for an incident with R2. This poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 20, 2023

Plan of correction: Licensee/Administrator to review reporting requirement regulations and provide proof of understandin by POC due date

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver amended report for Case Management dated 06/15/2023. LPA Mendivil visited facility on 06/15/2023 and observed a resident had eloped. LPA Mendivil met with Ben Briones and discussed amended report to assess CIVIL PENALTY. An exit interview was conducted with Ben Briones and a copy of this report, and amended LIC 809-D with LIC 421 IM and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jun 20, 2023

Type of visit: Case Management - Deficiencies

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit in conjunction with Complaint Control Number 22-AS-20230613154512. LPA was greeted and granted entry into the facility by caregiver Ben Briones and explained the reason for the visit. During the course of the complaint visit LPA Mendivil reviewed Resident's 1 (R1) Physician Report (LIC 602) dated 01/02/2023, which indicates R1 is not allow to leave the facility unassisted. LPA Mendivil was not able to speak to R1 as R1 left the facility unassisted at 8am. Staff indicated R1 signed out and left and did not report when they would return 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, Jun 15, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 16, 2023

87464 Basic Services (f) Basic services shall at a minimum include: (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 evidence by, LPA observed a resident had left the faciltiy unassisted, when 602 stated R1 cannot leave the facility unassisted. This causes an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Licensee to review all residents' LIC 602 and provide in service regarding residents ability to leave facility

Allegation investigated: Staff failed to keep facility free of vermin

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 Ben Briones and explained reason for the visit. Administrator/Licensee Brevet Dao arrived at 3:10pm. The department received a complaint on 05/24/2023 and the initial 10 day visit was conducted on 05/25/2023. During the visit LPA toured the facility and interviewed residents and staff. Regarding the allegation Staff failed to keep facility free of vermin, the investigation revealed the following: During the tour of the facility LPA Mendivil observed rodent droppings present in the living room, hallway cupboard and in resident's closets. Based on interviews with residents 1 out of 5 confirm they have seen rodents present in the facility. 4 out of 5 indicate they have not seen or heard any rodents, and the final resident was not available to interview due to not being oriented to space and time. CONT on 9099-C dated 05/25/2023 Substantiated Based on interviews with staff indicated they have not seen a presence of rodents. Interviews with Administrator Brevet Dao indicate she has a contract with a pest control company and they have been out to the house to initiate protocols to safeguard from pest. Therefore based on the preponderance of evidence through observation of rodent droppings and interviews the allegation that Staff failed to keep facility free of vermin is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. Civil Penalty assessed based on repeat violation. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, May 25, 2023 · control 22-AS-20230524125330

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: May 26, 2023

87303 Maintenance and Operations: (a )The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requriement was not met as evidence by the facility had the present of rodent droppings in mulitple locations. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 25, 2023

Plan of correction: Licensee to immediately clean kitchen pantry and clean the facility and provide proof to LPA by POC date. Licensee to contact pest control company and provide LPA with date and time of next visit and forward proof to LPA by 06/01/2023.

Type of visit: Case Management - Other

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver amended findings for complaint 22-AS-20230301162939 LPA delivered amended findings to facility on 04/20/2023. LPA Mendivil met with Ben Briones and discussed amended report. An exit interview was conducted with , and a copy of this report, and amended report of findings delivered on 04/20/2023 were provided at exit.the state’s words, verbatim · CDSS document, May 19, 2023

Type of visit: Office

On today's date, Licensing Program Manager (LPM) Alisa Ortiz and Licensing Program Analyst (LPA) Andrea Mendivil met with Licensee Brevet Dao on this day for the purpose of discussing ongoing facility issues. The following was discussed: · Concerns regarding recent Substantiated complaints at Licensee’s facility Iris Guest Home. · Licensee's responsibilities of facility oversight · Licensee's requirement to assess residents prior to admission and ensure all preadmission paperwork is completed · Licensee's responsibility to ensure all staff is trained and training is up to date · Licensee’s responsibility to ensure physical plant is maintained and free of insects and vermin · Licensee’s responsibility to ensure medications are received, provided and maintained as prescribed The Licensee Stated as following during today's meeting: · Licensee will designate a staff as Facility Designated Administrator Back up - Licensee will retrain staff in personal rights and medications - Licensee will provide more oversight at the facility including spending more time at the home - Licensee will review and maintain all facility paperwork - Licensee will ensure facility is following all required policy and procedures regarding rate increases and evictions CONT on LIC 809- C During the meeting the Department’s Technical Support Program (TSP) was discussed with Licensee. Licensee expressed interest in Technical Support Program (TSP) and has agreed to participate. Licensee was made aware of the seriousness of recent substantiated allegations and deficiencies issued. Licensee was placed on a compliance plan for a period of one years time effective 04/272023. An exit interview was conducted with Licensee Brevet Dao and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 27, 2023

Allegation investigated: Facility unlawfully raised resident's rent Facility unlawfully evicted 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 facility by caregiver Bonifacio Briones and explained the reason for the visit. Administrator Brevet was available by phone. The Department received a complaint on 03/06/2023 and conducted the initial visit on 03/14/2023. LPA Andrea Mendivil obtained copies of pertinent documents including but not limited to: admission agreements and resident files, and rent increase letter. In regards to the allegations Facility unlawfully raised resident's rent and Facility unlawfully evicted resident the investigation revealed the following: Regarding the allegation facility unlawfully raised resident’s rent, LPA verified that 3 of 6 residents in care received a written notice of rate increase from Administrator Dao via text message. Text messages received included a photograph of a written 60 day notice dated February 25, 2023 notifying individuals of rate increase. Substantiated Per written notice observed, written notice failed to address general description of the additional costs. LPA spoke with Administrator Dao who reported the rate increase was due to a change in basic service costs. Administrator Dao did not submit written change in Plan of Operation and/or Admission Agreement to the Department prior to providing residents with notice. Regarding the allegation facility unlawfully evicted resident, it was reported Resident 1 (R1)’s responsible party received a text message from Administrator Dao asking them to relocate R1 from the facility due to the facility needing to close. Text message received did not include required written standards as outlined in Eviction Procedures per Title 22 Section 87224. Therefore, based on the preponderance of evidence gathered, the allegations that Facility unlawfully raised resident's rent and Facility unlawfully evicted resident are determined to be Substantiated. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Administrator and a copy of this report, LIC9099-D, and appeal rights was provided at the time of exit. During the investigation LPA confirmed rate increases were not specific to one resident but rather provided to multiple residents due to increase utilities, commodities and workforce costs. Although it was confirmed Dao had made multiple attempts to contact resident/ their responsible party documentation provided could not confirm contacts were made with a malicious intent. Therefore, based on the preponderance of evidence gathered, the allegations that Facility Administrator is retaliating against Resident is UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. An exit interview was conducted with Administrator and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Apr 25, 2023 · control 22-AS-20230306140958

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(4) · Plan of correction due date: Apr 26, 2023

(g) Admission agreements shall specify the following:(4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change... This requirement was not met as evidence by Administrator did not update Plan of Operations or Admission Agreement with new rate. This poses a potential risk to personal rights for persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2023

Plan of correction: Administrator to update admission agreements and Plan of Operations with update basic rate and what is included with basic rate.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Apr 26, 2023

(a) Eviction Procedures: (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidenced by: Administrator sent R1's responsible party a text message asking R1 to relocate.the state’s words, verbatim · CDSS document, Apr 25, 2023

Plan of correction: Administrator to review eviction procedures and update in Plan of Operations/ Admission Agreement by POC due date and forward proof to LPA.

Allegation investigated: Facility is not following resident's physician dietary orders.

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 Bonifacio Briones. Administrator Brevet Dao was available by phone. The department received a complaint on 04/03/2023 and the initial visit was conducted on 04/07/2023. During the visit LPA Mendivil obtained copies of physician reports , physician’s dietary recommendations, and sample menu. Regarding the allegation facility is not following resident’s physician dietary orders, the investigation revealed the following: Per documentation Resident 1 (R1) was admitted to the facility on 02/02/2022. Based on review of LIC 602 Physicians Report dated 01/20/22 R1 does not require a special diet. LPA Mendivil obtained a copy of a letter, dated 11/03/2022, from R1’s physician with recommendation for dietary guidance. Unsubstantiated The letter serves as a recommendation to avoid processed foods, high carb vegetables, potatoes, and rice. Based on interviews with Administrator Dao, Administrator acknowledged she has received the dietary recommendations from R1’s responsible party. Administrator Dao reported that the facility attempts to follow all recommendations and acknowledges will continue to follow recommendations as much as possible. Therefore, based on the preponderance of evidence gathered, interviews conducted, records reviewed, and observations made the allegation that facility is not following resident’s physicians dietary orders is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was providedthe state’s words, verbatim · CDSS document, Apr 25, 2023 · control 22-AS-20230403084619

Allegation investigated: Facility staff yells at residents. Facility staff threw resident's wheelchair. Facility staff does not ensure that the facility is maintained at a comfortable temperature for the residents. Facility staff does not properly store bed linens.

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into facility by caregiver Bonifacio Briones and explained the reason for the visit. Administrator Brevet Dao was available by phone. The Department received a complaint on 03/06/2023 and conducted the initial visit on 03/14/2023. LPA Andrea Mendivil obtained copies of pertinent documents including but not limited to: resident roster and LIC 500 (Personnel Report). In regards to the allegations Facility staff yells at residents; Facility staff threw resident's wheelchair; Facility staff does not ensure that the facility is maintained at a comfortable temperature for the residents; Facility staff does not properly store bed linens the investigation revealed the following: Regarding the allegation Facility staff yells at residents, interviews conducted with Staff 1 (S1) and Administrator Dao deny allegations of yelling. S1 confirmed they do speak in a loud voice when speaking with residents due to residents being hard of hearing. Substantiated Interviews conducted with two of six residents in care confirmed that S1 does yell at residents. The remaining four residents were unavailable and/or unable to be interviewed due to communication barriers. LPA Mendivil reviewed S1’s personnel file and confirmed S1 has not received current training on resident’s personal rights. Training observed on file expired March 16, 2023, meaning it is older than 12 months time period. Although it does not appear S1’s elevated voice was done with malicious or mal intent, based on interviews conducted with S1 and multiple residents in care, the allegation is determined to be Substantiated. It was alleged facility staff threw resident’s wheelchair due to staff becoming agitated and physically throwing Resident 1 (R1)’s wheelchair. Interviews conducted with S1 and Administrator Dao deny allegation. Interviews conducted with residents in care confirmed S1 can be rough at times when handling residents and/or their belongings. Although it does not appear S1’s rough handling was done with malicious or mal intent, based on interviews conducted with residents in care the allegation is determined to be Substantiated. Regarding the allegation Facility staff does not ensure that the facility is maintained at a comfortable temperature for the residents. Based on observations made during LPA’s visit to the facility on 03/14/2023, LPA observed the facility to be maintained at a comfortable temperature meaning residents did not appear to be over heated, sweating and/or unreasonably cold. Temperature within the facility appeared to be maintained within regulatory requirements. Interviews with 3 out of 6 residents indicate that the temperature in the facility is comfortable. The remaining three residents were unable and/or refused to be interviewed. During a separate complaint investigation dated 1/20/2023 the allegation that Facility has no heat was substantiated. Therefore, the allegation facility failed to maintain temperature within regulatory requirements is deemed to be Substantiated. The facility was previously cited on 1/20/2023 for violation and has since corrected deficiency. Regarding the allegation facility does not properly store bed linens, during previous visit dated 03/14/2023 LPA Mendivil observed bed linens being stored in a pile on facility outside patio. Patio was uncovered and accessible to outside elements. During follow up visit dated 4/7/2023 LPA observed linens had been freshly cleaned, sorted, and restored in a linen closet located within the facility. Based on LPA’s observations, the allegation that facility does not properly store bed linens is deemed to be Substantiated. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Administrator and a copy of this report, LIC9099-D, and appeal rights was provided at the time of exit.the state’s words, verbatim · CDSS document, Apr 25, 2023 · control 22-AS-20230329103817

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 1, 2023

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: 2 out of 6 residents stated that S1 yells. This poses a potential risk to persons safety in care.the state’s words, verbatim · CDSS document, Apr 25, 2023

Plan of correction: Administrator to conduct in staff training on personal rights and provide LPA with proof by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 1, 2023

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement was not met as evidence by: S1 has handled residents belongings in a rough manner. This poses a potential risk safety to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2023

Plan of correction: Administrator to conduct in staff training on handling residents belongings and provide LPA with proof by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Apr 25, 2023

(3) Equipment and supplies necessary for personal care ... shall be readily available to each resident... (C) Clean linen... The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair… This requirement was not met as evidence by LPA observed linens in outside patio on 03/14/2023. This poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Apr 25, 2023

Plan of correction: Administrator has since corrected issue. Linens are clean and properly stored inside closet in the facility.

Allegation investigated: Facility staff lack emergency disaster training Facility does not have emergency oxygen An uncleared individual is living in facility

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit in order to conduct a complaint visit. LPA was greeted and granted entry into the facility by Leo Garias and explained the reason for the visit. Brevet Dao was not present. The Department received a complaint on 10/31/2022 and conducted the initial visit on 10/31/2022. LPA Mendivil obtained copies of pertinent documents including but not limited to: staffing documents, medication records and facility roster. In regards to the allegations facility staff lack emergency disaster training, facility does not have emergency oxygen, and An uncleared individual is living in facility, the investigation revealed the following: Unfounded For allegation facility failed to maintain temperature within regulatory requirements. Based on observations made during LPA’s visits to the facility on 10/31/2022, LPA observed the facility to be maintained at a comfortable temperature meaning residents did not appear to be over heated, sweating and/or unreasonably cold. Temperature within the facility appeared to be maintained within regulatory requirements. Interviews with 3 out of 6 residents indicate that the temperature in the facility is comfortable. The remaining three residents were unable and/or refused to be interviewed. During a separate complaint investigation dated 1/20/2023 the allegation that Facility has no heat was substantiated. Therefore, the allegation facility failed to maintain temperature within regulatory requirements is deemed to be substantiated. The facility was previously cited on 1/20/2023 for violation and has since corrected deficiency. Regarding the allegation that facility failed to address pest infestation, the Investigation determined the facility does have a pest infestation, including but not limited to roaches and rodents. During LPA’s multiple visits to the facility LPA observed multiple mouse traps along with rodent droppings in multiple resident rooms. Interviews conducted with 2 of 6 residents confirmed residents have not seen rodents in the facility, however, acknowledge seeing rodent droppings on multiple occasions. Although the facility implemented rodent traps at the facility, the facility failed to properly address the pest infestation as evidence by the on going rodent droppings visible in the facility despite having implemented rodent traps. Therefore, the allegation is determined to be Substantiated. Regarding the allegation that the facility lacks emergency lights, the investigation determined that the facility does not have emergency lighting. Based on interview with Administrator Brevet Dao it was reported that the facility utilizes hallway and bathroom lights as lights at night. This does not constitute emergency lighting as it would not be available during a potential power outage. Therefore, the allegation is Substantiated. For the allegation that resident bedrooms have insufficient lighting, LPA Mendivil observed 2 out of 3 resident bedrooms had missing light bulbs. It appears the facility utilizes natural light during the day and due to missing light bulbs, the facility does not have sufficient lighting for night time. Therefore, the allegation is Substantiated. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Administrator and a copy of this report, LIC9099-D, and appeal rights was provided at the time of exit. Regarding the allegation Facility staff lack emergency disaster training, LPA reviewed five of five staff files. Of the staff files reviewed, LPA confirmed five of five staff have documentation of current emergency disaster training. Staff interviewed were able to explain the process of disaster training. Interviews with staff indicate that they are also CPR trained. LPA verified one of five staff present has a current CPR training. The remaining four of five staff have current first aid training. Therefore the allegation that facility staff lack emergency disaster training is determined to be Unfounded. Regarding the allegation that facility does not have emergency oxygen, during the investigation LPA confirmed that facility maintained multiple spare oxygen canisters in the facility garage. LPA confirmed canisters to be full and operational. Therefore the allegation that facility does not have emergency oxygen has been determined to be Unfounded. LPA Mendivil cross reviewed facility Personnel Summary List and all staff listed on LIC 500 (Personnel Report) and confirmed all staff listed are associated with the facility. LPA Mendivil also reviewed documentation such as, but not limited to, staff files of which all present employees were reflected as having the necessary criminal background clearance. Therefore the allegation Uncleared individual is living in the facility has been determined to be Unfounded. An exit interview was conducted and a copy of this report was provided at the time of exit. * Due to technical difficulties LPA was unable to print documents, documents were emailed to Administrator and a copy was retained on file.the state’s words, verbatim · CDSS document, Apr 20, 2023 · control 22-AS-20221031081441

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 21, 2023

87303 Maintenance and Operations: (a )The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requriement was not met as evidence by the facility had multple rodent traps, but the present of rodent droppings were still visble. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: Administrator has provided LPA with pest control contract which is for pest control to visit facility quaterly and as needed. Retained copy on file.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(h) · Plan of correction due date: Apr 26, 2023

87303 (h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used. This requirement is not met as evidence by Administrator stated that the facility utilizes hallway and bathroom lights on at night. Facility does not have emergency lighting set up.the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: Administrator to distrubute emergency lighting to appropiate areas.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(B) · Plan of correction due date: Apr 26, 2023

87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care ... shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: B) Bedroom furniture, which shall include, for each resident,.. a lamp, or lights sufficient for reading... This requirement was not met as evidence by 2 out of 3 residents bedrooms have missing light bulbs. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: Administrator to replace all missing light bulbs and provide proof to LPA by POC due date.

Allegation investigated: Facility is malodorous. Ombudsman poster is not posted in facility. Facility did not administer medications to resident. Resident was not given an admission agreement.

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into facility by caregiver Leo Garias and explained the reason for the visit. Administrator Brevet Dao was notified of LPA’s arrival and joined via telephone. The Department received a complaint on 03/01/2023 and conducted the initial visit on 03/02/2023. LPA Alvaro Ramirez obtained copies of pertinent documents including but not limited to: medication records and admission agreements. In regards to the allegations Facility is malodorous; Ombudsman poster is not posted in facility; Residents are not provided adequate bedding; Facility did not administer medications to resident; and Resident was not given an admission agreement, the investigation revealed the following: Regarding the allegation Facility is malodorous, LPA experienced a strong urine like odor coming from the bedroom of Resident 1 (R1) and Resident 2 (R2) during multiple visits to the facility. ** This is an amended report ** Substantiated LPA confirmed R1 and R2 require incontinence care assistance from facility staff. LPA interviewed residents but was unable to determine frequency of incontinence services. Regarding the allegation the Ombudsman poster is not posted in the facility, LPA Alvaro Ramirez confirmed via photograph taken that Ombudsman poster was not properly posted in a visible location. While the facility was observed to have a poster present in the building, poster was observed laying on an end table in facility living room. Regarding the allegation Facility did not administer medications to resident, LPA confirmed Resident 3 (R3)’s medication was being rationed by facility staff due to pharmacy failing to provide refill for prescription on time. LPA spoke with Administrator Brevet Dao who stated she did reach out to the pharmacy once notified the pharmacy failed to refill medication on time. R3’s physician was not notified of the missed medication dosages. It was alleged resident was not given an admission agreement due to R3 not receiving an admission agreement. LPA interviewed R3 who confirmed they did not receive a copy of admission agreement upon moving in. R3 reported they were provided an Admission Agreement on 3/04/23 by Administrator Dao for signature. R3 moved into the facility on 12/18/2021. Therefore, based on the preponderance of evidence gathered, the allegations that Facility is malodorous; Ombudsman poster is not posted in facility; Residents are not provided adequate bedding; Facility did not administer medications to resident; and Resident was not given an admission agreement are determined to be Substantiated. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with Administrator and a copy of this report, LIC9099-D, and appeal rights was provided at the time of exit. * Due to technical difficulties LPA was unable to print document, document emailed to Administrator Therefore based on preponderance of evidence through records reviewed, observations made and interviews conducted the allegation Residents are not provided adequate bedding 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 and confidential names list was provided.the state’s words, verbatim · CDSS document, Apr 20, 2023 · control 22-AS-20230301162939

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Apr 26, 2023

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidence by the facility bedroom of R1 and R2 had a strong urine odor. This poses a potential health and safety risk to persons in care,the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: Administrator create a schedule for cleaning and incontinence care and provide proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(12) · Plan of correction due date: Apr 26, 2023

To contact the ... ombudsman ... The licensee shall post the telephone numbers and addresses for the local offices ... and ombudsman program, in accordance with Section 9718 of the Welfare and Institutions Code, conspicuously in the facility foyer, lobby, residents’ activity room, or other location easily accessible to residents. This requirement was not met as evidence by LPA Ramirez took photographic evidence of ombudsman poster on a table in the living room. This poses a potential health and safety risk to persons in care,the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: Administrator has since corrected the deficency. Ombudsman poster is displayed in the facility entryway.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87464(f)(4) · Plan of correction due date: Apr 21, 2023

87464 (f)Basic services shall at a minimum include:(4)Personal... assistance with taking prescribed medications...This requirement was not met as evidenced by based on interviews facility was rationing R3's medication.the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: Administrator to ensure all medications are refiled as necessary.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(C) · Plan of correction due date: Apr 21, 2023

Admission Agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, and the licensee no later than seven days following admission. This requirement was not met as evidence by R3 did not sign agreement until 3/4/2023. R3 entered facility on 12/18/2021 This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: Administrator has since retained a signed copy on file and provided R3 with a copy of signed admission agreement,

Type of visit: POC

Licensing Program Analyst (LPA) Andrea Mendivil 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 03/14/2023. LPA was greeted and granted entry into the facility by Caregiver Leo Garias and explained the reason for the visit. Administrator Brevet Dao arrived at 9:40 am. *Deficiency cited under Title 22 Regulation 87506 (a) pertaining to Resident Records has been cleared. Resident files are at the facility and accessible. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87405 (a) pertaining to Administrator - Qualifications and Duties has been cleared, Licensee provided an LIC 308 with a designated back up administrator. Deficiency cited under Title 22 Regulation 87465 (h) (2) pertaining to Incidental Medical and Dental Care has NOT been cleared. LPA Mendivil observed unsecured medications in refrigerator. CIVIL PENALTY ASSESSED. 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 Administrator and a copy was left with facility representative as well as appeal rights.the state’s words, verbatim · CDSS document, Apr 7, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Apr 8, 2023

(h) The 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 responsible for the supervision of the centrally stored medication. This was not met as evidenced by LPA observed unsecured medication in refrigerator this is a health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 7, 2023

Plan of correction: Licensee placed medications in locked box in refrigerator. Staff will take a picture of locked box and provide to administrator it is locked after medications are administered.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) made an unannounced visit to the facility for the purpose of conducting a Case Management inspection based on deficiencies observed during a complaint investigation visit for complaint #22-AS-20230317113524. Upon arriving at the facility and before entering the premises, LPA could hear the facility's sound alarm from the smoke detectors inside the facility. Upon ringing the bell, knocking the door and being greeted by facility's caregiver staff, LPA was able to confirm that the alarms were being triggered by cooking fumes inside the house in spite of the extractor fan running and kitchen window being open. A deficiency is being issued per Title 22 Division 6 of the California Code of Regulations. Later during the visit, LPA requested, obtained and reviewed facility records for the six individuals currently in care. Upon review of the residents' physician records, the following was observed: - One resident admitted to the facility on January 14, 2023 had a physician report showing a date of examination of November 15, 2021, which is in excess of the required maximum of a year prior to admission. - Two residents with a Dementia diagnosis show outdated physician reports that have not been reassessed over the past calendar year. Two deficiencies to Title 22 regulations are cited to that extent. An exit interview was conducted and a copy of this report, citations and appeal rights were provided to the facility representative via email.the state’s words, verbatim · CDSS document, Mar 20, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 3, 2023

The California Code of Regulations 87468.1(a)(2) on Personal Rights of Residents in All Facilities states that (a) Residents (...) shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Upon arriving at the facility, LPA observed smoke detectors being triggered across the entire facility by cooking fumes. This constitute a potential risk to the health, safety and personal rights of the individuals in care.the state’s words, verbatim · CDSS document, Mar 20, 2023

Plan of correction: Licensee to ensure that all smoke detectors are in adequate working order. The extractor fan shall be verified to be of a sufficient capacity to avoir smoke alarms being triggered by staff cooking meals for the residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: Apr 17, 2023

The California Code of Regulations Section 87458(a) on Medical Assessment states that "Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year." This requirement is not met as evidenced by Record for one resident admitted to the facility on January 14, 2023 had a physician report showing a date of examination of November 15, 2021. This constitutes a potential risk to the health, safety and personal rights of the individuals in care.the state’s words, verbatim · CDSS document, Mar 20, 2023

Plan of correction: Licensee to obtain an updated medical assessment for the resident in question before the plan of corrections due date of April 17, 2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Apr 17, 2023

The California Code of Regulations Section 87705(c)(5) on the Care of Persons with Dementia states that: "(5) Each resident with dementia shall have an annual medical assessment (...) done at least annually(...)." This requirement is not met as evidenced by: Based on a review of resident records kept at the facility, two residents with diagnosed dementia are showing medical assessments that have been conducted more than a year prior to the inspection's date. This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Mar 20, 2023

Plan of correction: Licensee to obtain updated medical assessments which shall include a reassessment of the resident’s dementia care needs before the plan of corrections due date.

Allegation investigated: Staff are not providing food in the quality and in the quantity necessary to meet the needs of the residents.

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 Leo Garias and explained the reason for the visit. The department received a complaint on 02/23/2023 and the initial visit was conducted on 03/02/2023 by LPA Alvaro Ramirez Jr. During the course of the investigation, the Department interviewed staff, residents and witnesses. In addition the department obtained copies of facility menu. Regarding the allegation staff are not providing food in the quantity and quality necessary to meet the needs of the residents, the investigation revealed the following: It was reported by witnesses that facility is providing residents with peanut butter and jelly sandwiches with spam for dinner and other meals include chicken and white rice. Based on observations by both LPAs Ramirez and Mendivil observed the refrigerator was stocked with eggs, bread, ham, and chicken. LPA Mendivil observed a sample menu on the refrigerator. CONT on 9099-c Unsubstantiated Based on interviews with Administrator Brevet Dao the menu is not always followed and it is modified. Administrator stated they try to accommodate all resident's dietary restrictions with are mostly low sodium and low carbohydrate meals. Interviews with staff indicate that groceries are purchased every 5 days Based on interviews with 3 out 6 residents stated they thought the food was sufficient in quantity but lacked in quality. 2 remaining residents stated that the food was satisfactory for both quantity and quality. The final resident was unable to be interviewed as they are oriented to time and space. All interviewed residents mentioned cereal or oatmeal for breakfast, chicken and rice for lunch and soup and sandwiches for dinner. Based on preponderance of evidence through observations and interviews the allegation that staff are not providing food in the quality and in the quantity necessary to meet the needs of the residents is UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was providedthe state’s words, verbatim · CDSS document, Mar 14, 2023 · control 22-AS-20230223151647

Type of visit: Case Management - Deficiencies

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced case management visit in conjunction with a complaint investigation for complaint control # 22-AS-20230306140958. LPA was greeted and granted entry to the facility by Leo Garias, caregiver and explained the reason for the visit. During the complaint investigation LPA Mendivil observed unlocked medication in the refrigerator for a resident that is no longer at the facility. LPA Mendivil asked for resident and staff files and the facility was unable to produce files within a timely manner. Administrator Brevet was not present at the time of visit and does not have a designated back up administrator. 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 Administrator and a copy was left with facility representative as well as appeal rights.the state’s words, verbatim · CDSS document, Mar 14, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Mar 15, 2023

(h) The 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 responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by facility had unsecured medication in the refridgerator which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 14, 2023

Plan of correction: Licensee to remove all medications from unsecured area and place in secured location by POC due date and forward proof to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Mar 20, 2023

All facilities shall have a qualified and currently certified administrator. . 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 is not being met as evidenced by: Based on observation and interviews conducted, Licensee failed to ensure there was a designation of responsibility issued to LPA during absence of administrator. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 14, 2023

Plan of correction: Licensee to submit a statement of understanding regarding designation of responsibility, LIC 308, and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Mar 16, 2023

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Administrator had files at a separate location and was unable to produce them at the facility, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Mar 14, 2023

Plan of correction: Licensee to electronically send over files to LPA by POC due date. Licensee to keep files at facility or electronic records for review.

Allegation investigated: Facility did not accompany resident to medical appointment Facility has insects

Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Staff Leo Garrais. Administer Brevet Dao spoke with LPA about the findings via telephone and stated she could not come to the facility. The complaint was investigated and consisted of interviews with the facility staff, Administrator and witnesses. The following was determined: Resident #1 (R1) was admitted into the facility on 12/27/22. R1 had Renal Failure and needed to attend Dialysis three times a week. R1 was confused and disoriented. and needed assistance with all his ADL's. He used a wheelchair to ambulate and needed assistance to get into the wheelchair. He could not leave the facility unassisted. Upon admission, no admission agreement was signed and according to staff and witnesses the POA was informed that the facility staff would take care of the transportation to medical appointments since R1 needed assistance. On 1/4/23, R1 was sent to Dialysis in an Uber. When he arrived, there was no staff to take him from the car into his appointment. Dialysis staff had to bring R1 inside and it was raining. Substantiated Based upon a review of records and the interviews conducted the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that R1 broke his hip at the facility. An exit interview was conducted and a copy of this report and appeal rights were provided to Leo Garrais. According to interviews a staff member and a medical transport with wheelchair access should have been used to assist R1. On 1/27/23 during the initial 10 day visit, LPA noted rodent droppings and baby cockroaches in the food pantry. Staff immediately removed all food and cleaned the pantry. Administrator Dao was also notified. Based upon a review of records and the interviews conducted the preponderance of evidence standard has been met and the allegations are substantiated. See LIC9099D for cited deficiencies per Title 22 regulation. An exit interview was conducted and a copy of this report and appeal rights were provided to Staff Leo Garrais.the state’s words, verbatim · CDSS document, Mar 3, 2023 · control 22-AS-20230127111023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 4, 2023

87465(a)(1)Incidental Medical and Dental Care-The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: On 1/4/23, R1 was sent to Dialysis in an Uber. No staff accompanied him and the Uber did not have wheelchair access. This poses an immediate health and safety risk as well as a personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 3, 2023

Plan of correction: Licensee agrees to meet with residents and/or their responsible party upon admission to sign an admission agreement and decide what type of transportation and supervision is needed and/or expected by the resident and family to meet the resident’s needs. Proof of understanding of this subsection will be provided by Licensee.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(2) · Plan of correction due date: Mar 4, 2023

Personal Accommodations and Services-The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by: On 1/27/2023, LPA observed rodent droppings and small cockroaches in the food pantry of the facility. This pose an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 3, 2023

Plan of correction: Staff #1 immediately removed food, cans and other containers from the pantry and cleaned the shelves. LPA notified Administrator Brevet Dao. Licensee agrees to hire an exterminator to rid the facility of cockroaches as well as rodents. Proof that an exterminator was contacted and a contract put in place will be provided by 3/3/23.

Type of visit: POC

Licensing Program Analyst (LPAs) Andrea Mendivil and Alvaro Ramirez conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 01/20/2023. LPAs were greeted and granted entry into the facility by Caregiver Leodigario Garias and explained the reason for the visit. Administrator Brevet Dao was unable to be present, but was available by phone. Deficiency cited under Title 22 Regulation 87303 (b) (1) ,licensee is using facility heater and facility temperature read at 70 degrees Fahrenheit Licensee has complied with the POC. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 3, 2023

Allegation investigated: Facility has no heat

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced complaint visit. LPA was greeted and granted entry into the facility by Caregiver Leo Garias and explained the reason for the visit. The department received a complaint on 01/17/2023. LPA Mendivil visited facility on 01/18/2023 . Regarding the allegation the facility has no heat,the investigation revealed the following: LPA Mendivil observed the thermostat at 66 degrees fahrenheit on 01/18/2023 during the initial 10 day visit. During the complaint delivering visit the thermostat read at 66 degrees fahrenheit. Interviews with residents indicate they were told the facility heat is not working. Substantiated Therefore based on the preponderance of evidence through interviews and observations the allegation that the facility has no heat is SUBSTANTIATED, meaning the complaint allegation is 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 facility representative.the state’s words, verbatim · CDSS document, Jan 20, 2023 · control 22-AS-20230117165840

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(1) · Plan of correction due date: Jan 26, 2023

87303 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 degree F, (20 degrees C). This requirement was not met as evidence by the facility thermostat read at 66 degrees. This poses a potential heatlh and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 20, 2023

Plan of correction: Administrator to send photo proof daily until 01/26/2023 that the thermostat is at or above 68 degrees as Administrator stated the heater is working and is on.

Type of visit: POC

Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 10/31/2022. LPA was greeted and granted entry into the facility by Caregiver Leodigario Garias and explained the reason for the visit. Administrator Brevet Dao was unable to be present, but was available by phone. Deficiency cited under Title 22 Regulation 87303 (b) Maintenance and Operation, licensee replaced all broken screens. 87203 Fire Safety, licensee repaired all non operational smoke alarms, all were tested during POC visit and all are operational. 87465 (h)(2) Incidental Medical and Dental Care, licensee corrected, medications were secured. 87465(h) (6) Incidental Medical and Dental Care licensee updated record keeping for medications for all residents. 87303 (a) Maintenance and Operation, licensee has set up a cleaning schedule and all openings have been sealed. 87307 (d) (6) Personal Accommodations and Services, licensee showed proof that all walkways were cleared Licensee has complied with the POC. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 19, 2022

Allegation investigated: Facility is not maintained clean Facility walkways are not free of hazards Facility screens are in disrepair & missing Facility fire alarm is in disrepair Medications are not stored properly Medication records are not being kept

On this day Licensing Program Analyst (LPA) Andrea Mendivil and Licensing Program Manager (LPM) Alisa Ortiz along with Rafael Perez Code Compliance Supervisor, Ines Guzman Code Compliance Officer and Orange County Fire Authority Representative R. D made an unannounced visit for the purposes of conducting an investigation into the above allegations. The investigation determined the following: At approx. 1:16PM LPM and LPA observed a rodent trap in facility kitchen along with rodent droppings. At 1:21PM rodent trap was observed under TV stand in living room. LPA and LPM also observed in resident bedroom #2 at 1:25pm. At 1:17PM 1:24pm ,1:25Pm and1:34PM LPA and LPM observed damaged and or missing screens throughout the home. At 1:17PM LPA and LPM observed a sticky brown substance on wall above the kitchen stove. At 1:18PM LPA and LPM observed damaged kitchen drawer. At 1:20 PM LPA and LPM observed fire alarm to be tapped over and nonoperational and a total of 3 smoke alarms were found to be nonoperational in facility. At 1:21PM wall outlet in resident’s bedroom was observed to be broken and exposing wires. CONT on LIC 9099-C Substantiated At 1:24PM LPA and LPM observed a hole in the wall of bedroom #2. At 1:29PM LPA observed rusted and broken tiles in shower. At 1:31PM dead roaches and rodent droppings. At 1:56PM LPA and LPM observed bike and discarded pictures obstructing walkway. At approximately 3PM LPM Ortiz and Administrator conducted a review of Resident 1 (R1) and Resident 2 (R2) medications. Per the review conducted resident's medications are not being kept and medications. Due to insufficient documentation, it remains unclear if resident's are receiving medications as prescribed. Based on the above information, the following allegations are deemed to be SUBSTANTIATED: Facility is not maintained clean; Facility walkways are not free of hazards; Facility lacks emergency lights; Facility screens are in disrepair & missing; Facility does not have emergency oxygen; Facility fire alarm is in disrepair; Medications are not stored properly; and Medication records are not being kept. The following is being cited per California Code of Regulations Title 22 Divison 6 Chapter 8. An exit interview was conducted and a copy of this report, confidential names list, appeal rights and civil penalty assessment was provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 31, 2022 · control 22-AS-20221031081441

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Nov 1, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: LPA and LPM observed rodents and pest present in facility along with rodent droppings. LPA and LPM observed sticky brown substance on kitchen wall and broken cabinet drawers. This poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2022

Plan of correction: Licensee agrees to set up daily cleaning schedule and seal all openings into the home. Licensee to provide proof by POC due date 11/14/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Nov 14, 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 was not met as evidence by: LPA observed discarded bike and paintings obsturcting walkway along side of house. LPA and LPM observed screws coming out of ground along other side patio/walkwa which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2022

Plan of correction: Licensee agrees to remove obstructions from walkways and provide picture proof of corrections by POC due date of 11/14/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b) · Plan of correction due date: Nov 14, 2022

87303 Maintenance and Operation (b) All window screens shall be clean and maintained in good repair. This is evidence by broken and/or missing screens in multiple resident bedrooms and kitchen window, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2022

Plan of correction: Licensee agrees to repair/replace broken and missing screens and provide proof of correction by POC due date of 11/14/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Nov 1, 2022

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This regulation was not met as evidence by: Based on observation smoke alarm in kitchen and two bedrooms was observed non-operationalis nonoperational and fire alarm pull was observed nonoperational and taped up., this poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Oct 31, 2022

Plan of correction: Licensee agrees to repair non-operational smoke alarms by POC due date of 11/01/2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Nov 1, 2022

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked....This regulation was not met as evidence by: Based on observation LPA observed an unlocked medication cabinet in facility entryway.This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2022

Plan of correction: Licensee agrees to set training date for all staff regarding medication management/storing by 11/01/2022. Training is to be completed by no later than 11/14/2022 and proof of training to be sent to LPA by 11/14/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(6) · Plan of correction due date: Nov 1, 2022

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: Based on medication reviewed for Resident 1 and Resident 2 medications records failed to consistently document date medication started and medications missed. It remains unclear if medications are being given as prescribed. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2022

Plan of correction: Licensee agrees to review all resident's medication and update record keeping. License to provide copies of updated records to LPA by COB 11/01/2022.

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: POC

On 10/17/2022, Licensing Program Analyst (LPA) conducted an unannounced visit to the facility for the purpose of following up on the plan of corrections resulting from the case management visit led on 10/14/2022. LPA was greeted and granted entry by caregiving staff after explaining the purpose of the visit. LPA requested caregiver to demonstrate where the cleaning supplies are currently stored. Caregiver showed supplies have been moved to the garage. LPA requested caregiver to show the medication storage. Centrally stored medication is adequately stored in a secure closet in the hallway leading to the bedrooms. Two type A violations observed on 10/14/2022 are cleared at this time. LPA conducted an exit interview, reviewed the report with the facility staff and left a copy of the report at the facility.the state’s words, verbatim · CDSS document, Oct 17, 2022

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced case management visit after observing multiple deficiencies at the twin facility operated by licensee. LPA was greeted and granted entry by caregiving staff after identifying himself and explaining the purpose of the visit. Administrator Brevet Dao was notified by phone, but was not available to assist with the visit in person. Infection Control measures were reviewed over the phone. Administrator agreed to review the final report over the phone as well and authorized her staff to sign on her behalf. After being greeted, LPA observed caregiver spray deodorizer around the hallway and bathroom after emptying a urine container in the toilet. Floor was afterwards observed to be wet and slippery throughout, which poses a safety hazard due to the risk of slipping. The medication central storage in a hallway closet is also observed to be unlocked at the time of the visit. Cleaning solutions and other potentially toxic substances are also observed to be stored in the laundry closet which is left unlocked after the padlock hinges broke off. Based on the observations made during today’s visit, three deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed over the phone with facility administrator and signed by authorized facility representative. A copy of this report along with appeal rights was provided and left at facility.the state’s words, verbatim · CDSS document, Oct 14, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 17, 2022

The California Code of Regulations Section 87465(h)(2) relative to Incidental Medical and Dental Care indicates that: "Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication." This requirement is not met as evidenced by: LPA observed that staff present had left the door to the medication closet unlocked while conducting the inspection visit. Caregiver states that they only lock the medication "when they sleep".the state’s words, verbatim · CDSS document, Oct 14, 2022

Plan of correction: Licensee will ensure that centrally stored medication remain locked and secure at all times.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f) · Plan of correction due date: Oct 17, 2022

The California Code of Regulations Section 87705(f) relative to the Care of Persons with Dementia indicates that: "The following shall be stored inaccessible to residents with dementia: (...) nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances" This requirement is not met as evidenced by: LPA observed sharp instruments, cleanings solutions, insecticide and/or rodenticide and nutritional supplements left unsecured throughout the physical plant.the state’s words, verbatim · CDSS document, Oct 14, 2022

Plan of correction: Licensee will ensure the safe and secure storage of all the identified objects and substances by the Plan of Correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 28, 2022

California Code of Regulations Section 87303(a) Maintenance and Operation states that "The facility shall be clean, safe, sanitary and in good repair at all times. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition". This requirement is not met as evidenced by: Licensing staff observed deodorizer spray making the floor wet and slippery during the inspection visit. Based on observation, 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 14, 2022

Plan of correction: Licensee will ensure the facility is kept clean, safe and sanitary before the plan of corrections due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to the facility today to conduct required 1 year inspection. During today’s visit, LPA met with Licensee Brevet Dao and explain the purpose of today's visit. LPA Frank toured the facility, inspected resident rooms and bathrooms. There are 5 residents residing in the facility and no active COVID-19 cases. LPA Frank reviewed centrally stored medications and records, reviewed food services, and inspected the kitchen. In addition, LPA Frank tested the hot water temperature, which measured 105 .8 degrees F in resident bathroom. Resident areas were noted to be a comfortable temperature. Smoke detectors and carbon monoxide detectors were tested and found to be operational. The facility also has fire extinguisher that was mounted and charged. LPA Frank confirmed food supply 2 day supply of perishables and 7 day supply of non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet. LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log, COVID posters throughout the facility. LPA Frank reviewed : 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report (LIC500); 3.) Emergency Disaster Plan (LIC610E); 4.) LIC 9020A Client Roster; LIC 808) Mitigation Plan; Current Liability Insurance, Infection Control Plan. Based on the observations made during today’s visit, the facility bathroom, toilet, kitchen sink and kitchen counter is unkempt, which poses an possible health, safety or personal rights risk to persons in care. An exit interview was conducted with the licensee, A copy of LIC 9102 Technical Assistance and LIC 809 was provided.the state’s words, verbatim · CDSS document, Jul 13, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA was greeted and granted entry by Licensee Brevet Dao and reason for visit was explained. Upon entry LPA was screened per COVID guidelines. LPA tour the facility with Licensee. The facility currently has 4 residents in care, of which 1 resident is receiving Hospice services. LPA observed residents taking naps in their room. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/sanitizer. LPA observed the screening/sanitizing station in the entrance of the facility. Visitors sign in and are screened for temperature. Facility takes resident temperatures daily and documents. Facility has COVID precaution postings as well as all required department postings. Facility has completed the Mitigation Plan and is approved. LPA observed adequate emergency food and water supply as well as the First Aid kit which contained all required items. Facility has all required items of PPE on site. LPA toured the outside grounds and observed ample shaded outside visitation area. Exit gate is unlocked and self latching. LPA observed the medication in locked closet. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation. Staff and most residents are vaccinated for COVID-19. Resident files contained updated emergency information as well as required department forms. 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 was provided.the state’s words, verbatim · CDSS document, Oct 1, 2021

Allegation investigated: Facility staff left resident in soiled clothing for an extended period of time. Facility staff do not assist resident with transfers out of bed. Facility staff are not providing resident with an adequate quality and quantity of food.

Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to deliver findings on the above allegation. LPA Frank met with Licensee Brevet Dao and explained the reason for the visit. During the course of the investigation, LPA interviewed staff as well as reviewed and obtained pertinent documentation such as Physician’s Report dated 09/1/2020, dated Electrocardiogram dated 8/26/20, COVID – 19 Negative report 8/31/20, Admission Agreement dated 9/1/20, Vitas Hospice care Medication list dated 10/1/20, Vitas Hospice Care visit list, Note from the family date- 11/10/20. LPA interviewed Staff 1 (S1) Staff 2 (S2) Resident 1 (R1) Vitas Nurse, residents daughter, *Investigation into allegation of Facility staff left resident in soiled clothing for an extended period of time is unfounded. Based on the interview with the R1,S1, S2, R1’s daughter R 1 was eating See’s Famous Old Time Candies (chocolate) and while he was eating the chocolate dropped on his cloths, not soiled but it was stain with chocolate. (Photo of the See’s Famous Old Time Candies provided) Unfounded *Investigation into allegation of Facility staff do not assist resident with transfers out of bed is unfounded. Interview of staff, R1’s Son and daughter and R 1 staff was assisting resident with transfer out of bed. Specially R 1 stated that S1 always help him. R 1’s daughter stated that Her father R1 going on has 3rd month of hospice care at Iris Guest Home on Berkeley. They were given 2 to 3 weeks of life for her father. At this facility he has improved so much.. Not only in health but mentally. He is happy at the facility. R 1 also stated that he is getting good care at the facility. *Investigation into allegation of facility staff are not providing resident with an adequate quality of food is unfounded. Interview of the staff and reviews of Admission Agreement, Physician’s report R1 was on liquid diet. R 1 has no dentures, no teeth. He was on soft diet as he chokes when swallowing. R 1 and R1’s daughter said that facility providing food according to R1’s needs. This agency has investigated the complaint and is determined to be UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegations of Facility staff left resident in soiled clothing for an extended period of time facility staff do not assist resident with transfers out of bed, Facility staff are not providing resident with an adequate quality and quantity of food were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.the state’s words, verbatim · CDSS document, Sep 9, 2021 · control 22-AS-20200921101517

Allegation investigated: Facility staff failed to access resident for injuries. Facility staff were not aware of resident's whereabouts on multiple occasions. Resident AWOL from the facility.

Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to deliver findings on the above allegation. LPA Frank met with Administrator Brevet Dao and explained the reason for the visit. During the course of the inves5tigation, LPA interviewed staff as well as reviewed and obtained pertinent documentation such as Physician’s Report dated 09/16/20, Admission Agreement dated 9/16/20, Vitas Hospice care Medication list dated 10/01/20, Doctor’s note dated 10/7/21, Vitas Hospice Care visit list, LPA interviewed Staff 1 (S1) Staff 2 (S2) Resident 1 and Vitas nurse. Investigation into allegation Facility staff failed to access resident for injuries is unfounded. Based on interview and reviews of Physician’s report dated 9/16/21 R 1 had imbalance of gate. On 10/8/20 she (R1) was outside on patio she fall and scratch her knee. Licensee and Vitas care hospice nurse observed the incident and Vitas nurse provided first aid to R1. R 1 had bruises on both her knees and a swollen right ankle Next day licensee checked her knees and it was bruised. R1 did not complaint having any pain or discomfort. Unfounded Investigation into allegation Facility staff were not aware of resident's whereabouts on multiple occasions is unfounded. Based on interview of R1, S1 and S 2. S 1 reported that yes, on 10/7/20 only one time R 1 went out to the store. He went right away and bring her back to the facility. After the incident licensee requested Doctor’s note indicates that R 1 not to leave the facility unassisted. Investigation into allegation Resident AWOL from the facility is unfounded. Based on the interview of S1, S 2 and R1. R1 reported that She loves to sit by her patio area or side of the home and read her Christian book, drink coffee and smoke as permitted. She After 10/7/20 (R1) did not AWOL from the facility. This agency has investigated the complaint and is determined to be UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegations of Facility staff failed to access resident for injuries, Facility staff were not aware of resident's whereabouts on multiple occasions and Resident AWOL from the facility were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.the state’s words, verbatim · CDSS document, Sep 9, 2021 · control 22-AS-20201009131947