Epic Assistance Care Home

Allegation investigated: Questionable Death. Staff gave resident alcohol without resident's representative's permission. Staff did not address resident's change in condition. Staff did not notify resident's representative about their change in condition. Staff do not treat resident in care with dignity. Staff do not provide adequate supervision to residents in care.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced inspection visit to deliver findings in the investigation of the allegations stated above. LPA was greeted and granted entry by caregiving staff after explaining the purpose of the visit. Licensee Liza Mesdjian was notified by telephone and read the report via telephone as well. LPA detailed the nine allegations that were under investigation. An initial complaint investigation visit was conducted on February 22, 2023. During the visit, LPA accompanied by caregiving staff conducted a tour of the physical plant including the kitchen, dining area, living room, private bedrooms, and shared bathrooms for the five residents in care at the facility. A follow-up investigation visit was led on April 19, 2023. CONTINUED ON FORM LIC9099-C Unfounded CONTINUED FROM FORM LIC9099-A Regarding the allegation that Resident was not accorded privacy during visitations, the following has been concluded: Based on interviews conducted with staff members, residents and multiple witnesses, no instance or reported interference with privacy during visitations was reported. It was initially alleged that resident R2 had been observed to be inebriated and interrupting visits to other residents on the back patio of the facility. Based on observation, interviews and records reviewed, the behavior described in the initial complaint is consistent with signs of the dementia diagnosis of resident R2 rather than to the influence of intoxicants. Witness 2 (W2) confirmed that he has always been accorded adequate privacy during his visits to his relative. Witness 3 (W3) stated that he felt he was always being provided with sufficient privacy during visits. The allegation is therefore deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation that Staff do not provide activities for residents in care, the following has been concluded: Witness 4 (W4), responsible party for resident 4 (R4) confirmed that the activities provided were in accordance with their relatives’ preferences and wishes which were also verified to be documented in R4’s assessment. W5 additionally confirmed that activities offered corresponded to their relative’s expressed wishes and preferences, which was also corroborated by LPA’s observation during the initial complaint investigation and follow-up facility visit. As a result, the allegation is deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 The allegations listed above have been filed regarding resident (R1). R1 was 96 year old at the time of her passing and a resident of Epic Assistance Care Home for the previous 3 years. Per her latest Physician’s Report dated February 6, 2022, resident was experiencing confusion, forgetfulness, signs of sundowning and depression. Resident was also noted to be unable to verbalize their needs, had bladder impairment with a Foley catheter in place and incontinence of bowel. Resident stated to require mild to moderate assistance with self-care and transfers. There was no use of alcohol. Medical diagnoses documented included Acute on Chronic diastolic Congestive Heart Failure (CHF), Pulmonary edema and Dementia. LPA requested, obtained, and reviewed the resident records for the five residents at the time of the visit. Medical records to Mission Hospital in Mission Viejo were received at the Regional Office for review on March 20, 2023. LPA reviewed the records. LPA Kevin Saborit-Guasch conducted additional witness interviews with relatives of the facility’s residents along with responsible parties on file. R1’s death certificate number 3052022265306 dated November 21, 2022, confirmed R1 passed away on November 9, 2022, with immediate cause of death of Acute Cardiopulmonary arrest and the underlying cause of vascular dementia. Records provided include the resident's face sheet, visit report for an Emergency Department visit dated November 9, 2022, stating a Chief Complaint of Altered Mental Status, with an oxygen saturation measured at 78% in the field and Emergency Medical Services personnel performing mechanical ventilation. Diagnoses include a Glasgow score of 3-8, hypotension, Acute renal failure, Dementia and a Urinary Tract Infection. Resident is noted to be undergoing septic shock alongside Acute renal failure and congestive heart failure. Resident infection status makes mention of a Methicillin-resistant Staphylococcus aureus added to the resident's file on May 15, 2021 and marked as resolved after the resident passed away on November 9, 2022. Resident also had an indwelling Foley catheter. The Mission Hospital admission notes indicate: “96-year-old female with a history of dementia, UTI, anemia with altered mental status. Patient was visiting with their son when they became unresponsive. Patient was hypotensive in the field. Patient brought in with a blood pressure of 49/25. On arrival I discussed code status and wishes with the daughter and son who indicate patient is DNR, no chest compressions and no intubation. He states they have treated with antibiotics and IV fluids in the past. On arrival patient is unresponsive, nonverbal, not following commands, has no doll's eyes and agonal respirations. Patient is not moving their extremities purposefully.” CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Regarding the allegation of Questionable Death, the following has been concluded: Based on review of medical records provided by Mission Hospital for the period of July 15, 2022 until November 9, 2022, death certificate and interviews conducted, the resident’s death was deemed to have been caused by natural causes, with immediate cause of death of Acute Cardiopulmonary arrest and the underlying cause of vascular dementia. Comprehensive Metabolic Panel done upon admission into the Emergency Department shows abnormal K, CO2, BUN, Creatinine, Albumin, Protein, Alkaline Phosphatase and eGFR levels, which are overall signs of kidney injury/disease consistent with the UTI diagnosis. There were no results of any lab work on ethanol done to reflect any alcohol consumption. An additional review of potential medications that could decrease alertness of resident-based resident’s latest Medication Administration Records dated November 2022 as well as the list of medications in hospital records upon admission on November 9, 2022 was completed. The listed side effects are mild to moderate. All the medications listed and reviewed can cause cognition impairment in addition to the documented dementia diagnosis. No indication of a regular consumption of alcohol having caused or contributed to the resident’s condition could be inferred by the evidence gathered. As a result, the allegation is deemed to be Unfounded meaning that meaning the allegation is false, could not have happened and/or is without a reasonable basis. Regarding the allegation that Staff gave resident alcohol without resident's representative's permission, the following has been concluded: Per statement of witness 1 (W1), resident R2 is medically cleared to consume one 2-ounce glass of wine alongside the dinner meal daily. The wine in question is being provided by the resident’s son and daughter and not purchased directly by the facility. The quantity stated to be provided is not consistent with the wine being served in greater amounts or to a higher number of residents. W1 stated "It's something that I bring from my business. We're not sharing it with anybody." LPA was able to observe dinner being served during the initial complaint investigation visit and was able to confirm the statements made during the interviews. Per statement of witness 2, it was confirmed that the responsible party for resident R1 had initially given staff permission to occasionally serve alcohol to resident R1 on festive occasions and later withdrew permission due to R1’s observed health condition. None of the evidence gathered corroborates the allegation. As a result, the allegation is deemed to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Regarding the allegation that Staff did not address resident's change in condition, the following has been concluded: When R1’s condition worsened on or around November 7, 2022, the responsible party and primary care physician were notified right away. R1 had been diagnosed with anemia and prescribed with supplemental oxygen by their primary care provider in October 2022. After notifying the interested parties, facility staff scheduled a doctor’s visit on November 8, 2022. When R1 was found unresponsive on November 9, 2022, in presence of their daughter, paramedics were activated timely and transferred the resident to Mission Hospital where they were admitted to comfort care shortly before passing away. No delay or lack of response by facility staff could be evidenced from interviews conducted and records reviewed. The allegation is therefore deemed to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Regarding the allegation that Staff did not notify resident's representative about their change in condition, the following has been concluded: Witness 2 (W2), indicated in the records reviewed as the responsible party and durable power of attorney for resident R1, states that overall they were notified whenever anything important needed to be reported. W2 states that on November 7, 2022, they received an early morning call from a facility caregiver that their mother was not doing very well. Doctor was called the next day and the R1 was put on oxygen. W2 states that overall he feels that the caregivers kept on top of communications with the responsible parties. W2 goes back to a fall incident with no injury that occurred in 2020 for which they were called right away. Those calls along with conversations held during the families' visits felt adequate to W2, who stated "I do not have a sense that they were withholding information". Witness 3 (W3) corroborated by stating that their relative was taken to the hospital a few times and facility staff always made sure to notify [the responsible party], regardless of the hour at which the transfer occurred. W2 states that they typically hear from facility staff before R1’s physician whenever an appointment is made or updates to R1’s treatment are made. The allegation is therefore deemed to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. CONTINUED ON FORM LIC9099-C CONTINUED FROM LIC9099-A Regarding the allegation that Staff did not follow proper Covid-19 safety protocols, the following has been concluded: Based on interviews conducted, approximately in October or November 2022, multiple staff members tested positive for COVID-19 and were kept on active duty providing care and supervision for residents with both positive- and negative-testing status. Administrator is stated to have justified her decision with the difficulty recruiting relief staff on short notice. However, the facility neither reported the positive cases within the facility, nor did they report being in a Critical Staffing Shortage as required by the updated Provider Information Notice PIN 22-09-ASC on Updated Guidance on Quarantine and Isolation for Facility Staff Exposed to COVID-19 and Return to Work for Facility Staff who Test Positive for Coronavirus Disease-19 (COVID-19) in order to bypass the Isolation guidelines applicable in Routine Staffing situations. W4 stated that approximately at the end of November 2022, they contracted COVID along with their family member placed at the facility and the two caregivers. Both caregivers are stated to have had to care for all of the residents which was justified to W4 by the facility owner as needed due to the difficulty or impossibility to gather additional staff. W4 states it was "not a good situation" and adds that at one point they received a call from resident (R4) hospice nurse who was worried R4 would pass away during the night. As a result, the allegation is deemed to be Substantiated, meaning that during the course of the investigation, the preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 Chapter 8 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were provided to facility representative. CONTINUED FROM LIC9099-C Regarding the allegation that Staff do not treat resident in care with dignity, the following has been concluded: Witness 4 (W4) stated that "I feel like both [caregivers] work hard to provide a nice clean environment. I looked at a lot of facilities before deciding to admit my family member there.” W3 stated "They're really good there, they're really nice people and more importantly my family member is happy there". W1 stated that they are at the facility three days a week along with other family member being there the other four days, and that they are in and out at different hours every time and never witnessed anything of concern. No residents or witnesses interviewed had any instance of disrespectful or inappropriate behavior by any caregiver to report, even as they were specifically asked if they did. As a result, the allegation is deemed to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Regarding the allegation that Staff do not provide adequate supervision to residents in care, the following has been concluded: Based on a review of records conducted at the facility along with multiple interviews with witnesses including R1’s responsible party, care and supervision provided by staff members was described as being very caring. W 1 indicated that their family are very satisfied with the staff and the level of care and attention provided by the caregivers to the residents. W1 states that one of their in-laws had resided at the facility prior to their passing and that this is what brought them to admit their own family member there when their needs made it necessary. W2 stated similarly that "It's not perfect, of course, but for me and most of the family members, it was far above the level of adequate. Most of us were comfortable to very comfortable with the regular care and activities provided at the facility." The allegation is therefore deemed to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jul 14, 2023 · control 22-AS-20230217143103

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(3) · Plan of correction due date: Jul 28, 2023

The California Code of Regulations Section 87470(b)(3) on Infection Control Requirements states that: “There shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others.” This requirement was not met as evidenced by: Interviews and licensee admission that staff members with confirmed COVID-19 diagnosis kept on providing care and supervision without the facility having reported a Critical Staffing Shortage.the state’s words, verbatim · CDSS document, Jul 14, 2023

Plan of correction: Licensee to update the Infection Control Plan and provide staff members with training on the recommendations in place to avoid the transmission of respiratory infections.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of documenting deficiencies observed during the initial investigation of the allegations in complaint reference #22-AS-20230217143103. LPA was greeted and granted entry by caregiving staff and spoke with administrator by telephone. During the investigation, it became apparent that at least two caregivers and one resident at the facility tested positive for COVID during the month of November 2022. Facility staff did not report the outbreak to the Department as required. Based on observation, interviews and records reviewed at the facility, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted via telephone and a copy of the report along with appeal rights was provided and left at the facility.the state’s words, verbatim · CDSS document, Jul 14, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Jul 28, 2023

The California Code of Regulations Section 87211(a)(2) on Reporting Requirements states that: "Occurrences, such as epidemic outbreaks (...) shall be reported within 24 hours (...) to the licensing agency". This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, multiple staff members and resident contracted COVID in November 2022 and were not reported to the Department. This constitutes a potential risk to the health, welfare and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2023

Plan of correction: Licensee to review applicable regulations and conduct staff training on Reporting Requirements.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to conduct a Required – 1 Year Annual inspection. Upon arrival LPA was greeted and granted entry by Carestaff AnnaMarie and Darwin Gamboa. LPA began inspection with introduction and visit purpose. There are currently 6 Residents residing and present at the facility. Facility currently has 4 Residents receiving Hospice care. Administrator (AD) Liza Mesdjian arrived shortly after. LPA along with Carestaff AnnaMarie conducted a tour of the inside and outside of the facility. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the Residents. Lighting is sufficient for safety and comfort. The facility is a one story, 7 bedroom, 8 bathroom home with a dining room, living room, kitchen, and attached garage. There is a back yard with a patio table and chairs and a canopy for shade. Resident bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were clean, faucets, showers and toilets were operational. Hot water in bathrooms was within regulatory requirements. Linen and hygiene supplies were stocked in hallway closets. Emergency Phone Numbers and Exit Plan were reviewed. Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of non-perishable and two (2) day supply of perishables. Emergency food and water supply is available. Smoke and Carbon Monoxide detectors are centrally wired and were found to be operational. Fire Extinguishers were charged and mounted, last serviced on 02/28/2023. Stove burners, microwave, dishwasher, washer, and dryer are operational. There is a locked location for chemicals and sharps in the kitchen. Laundry is done in the laundry room. The garage is used for storage. Medications are centrally stored and locked in a locked kitchen cabinet. LPA reviewed medication for Residents. Medications reviewed appear to have been dispensed accurately. (see LIC809C) First-Aid Kit and Activity Supplies, were observed and available. There is a working land line at the facility. The LIC610, Emergency Disaster Plan is posted. Facility’s licensing fees are fully paid. Indoor passageways are free of obstruction. LPA observed a washer, recliner, old mattress outside in backyard. Exit gate is self latching. LPA reviewed 6 Resident files. Files showed that three of six Physician's Reports indicated a confirmed Dementia diagnosis yet were dated by up to two years prior. LPA reviewed 2 Carestaff files. Facility staff do not have documented required training. Administrator Certificate expires on 07/29/2024. LPA interviewed Residents and Carestaff. Based on the information received during this visit today in the areas reviewed, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report will be sent to email on file.the state’s words, verbatim · CDSS document, Mar 30, 2023

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of documenting deficiencies observed during the initial investigation of the allegations in complaint reference #22-AS-20230217143103. LPA was greeted and granted entry by caregiving staff and spoke with administrator by telephone. During the health and safety tour of the physical plant, LPA observed that the mounted fire extinguisher had maintenance tags dated August 2021, meaning the required maintenance is outdated by six months. A review of resident records at the facility showed that four out of the five physician reports indicated a confirmed dementia diagnosis yet were dated by up to two years prior and were therefore outdated per the Title 22 regulations requirements. The physician report for resident R1 indicates that upon admission, resident was healing from a Stage 3 dermal ulcer. No records of an exemption request to admit a resident with a Prohibited or Restricted Health Condition were found. A Technical Violation advisory is issued to the licensee. LPA was able to verify administrator's Liza Mesdjian's administrator certificate is current. However, the certificates posted in facility per Title 22 regulations are shown to be outdated and related to individuals no longer associated to the facility. A Technical Assistance advisory note is issued. Based on observation and records reviewed at the facility, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted via telephone and a copy of the report along with appeal rights was provided and left at the facility.the state’s words, verbatim · CDSS document, Feb 22, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 6151(e)(3) · Plan of correction due date: Mar 22, 2023

The California Code of Regulations Title 7 Section 6151(e)(3) indicates that: "Portable fire extinguishers shall be subjected to an annual maintenance check. " This requirement is not met as evidenced by: Based on observation and record review, fire extinguisher maintenance is out of date since August 2022 which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: Licensee will contract a licensed vendor to performed the required annual maintenance on the fire extinguishers present within the physical plant and provide documentation thereof to Licensing Program Analyst before the Plan of Corrections due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: Mar 22, 2023

The California Code or Regulations Section 87705(c)(5) on the Care of Persons with Dementia states that: "Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, (...) This requirement is not met as evidenced by: Based on review, the four resident records observed to include an outdated physician report for residents with confirmed dementia diagnoses, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: Licensee is to schedule appointments with the primary care physician of all residents with a confirmed dementia diagnosis and submit the updated physician reports resulting from the visits to LPA before the plan of correction's due date.

Type of visit: Prelicensing

On this day, Licensing Program Analyst (LPA) conducted a scheduled follow-up visit for the purpose of completing the pre-licensing for the facility. LPA was greeted and granted entry by caregiving staff. LPA accompanied by administrator Simona Aziza toured the facility and was able to observe that a fireplace screen has been put in place. Nightlights have also been installed in each bedroom as well as in the hallways and kitchen in order to secure nighttime circulation in the physical plant. All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. An exit interview and a copy of the report were provided at the time of the exit.the state’s words, verbatim · CDSS document, Apr 28, 2022

Type of visit: Prelicensing

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made a scheduled visit to the facility for the purpose of conducting the pre-licensing verifications required for a change of ownership. At approximately 12:00pm, LPA was greeted upon arrival by prospective licensee Liza Mesdjian and granted entry. Facility is a one-story house with an attached garage. Six (6) bedrooms are assigned to residents and one (1) bedroom is assigned to staff. The current census is six (6) with two (2) residents currently under hospice care. The residents are observed to be relaxing in their bedrooms or in the common areas and appears well taken care of. LPA accompanied by administrator started by touring the physical plant. Hallways are clear of clutter and debris; adequate furnishing elements are being provided to the residents. The bathrooms used by residents are equipped with non-slip mats and grab bars and displayed hand washing signs. Hot water is measured to be 106 degrees in the kitchen and 105 degrees in one of the bathrooms. An ample supply of linen is available to residents. Smoke detectors are present in each room and found to be operational as well as one carbon monoxide detector in a central hallway. The exterior of the physical plant is free of clutter and debris. Perimeter gates are self-latching and easy to open in the eventuality of an evacuation. An ample supply of perishable and non-perishable food is on hand as well as emergency food and water supply. Weekly nutrition plans are displayed in the kitchen. A sufficient supply of PPE is also observed. Cleaning supplies and toxics are stored securely under the sink. Medication assigned to each resident is centrally stored in bubble packs and locked. Staff and resident files are stored on the premises. Two resident files are observed to include all required documentation, with some documents dated beyond the required updating period. Licensee is informed of the need to conduct emergency contact and physician reports updates annually once licensed. CONTINUED IN LIC809C CONTINUED FROM LIC809 Emergency disaster plan has been provided and reviewed with the licensing application. The mitigation plan has been submitted to Community Care Licensing (CCL) as well. In order to be in compliance to be licensed, the prospective licensee will need to address the following items: - Two missing locks needed to secure the cabinets where cleaning supplies are stored in the laundry room will need to be replaced. All toxics including room deodorizers need to be securely stored. - A screen will need to be installed in front of the dining room fireplace - Night lights will need to be installed in the bedrooms and hallways to allow secure access to the bathrooms at night. - Supplements, medication and potential toxic substances stored in the staff bedroom will need to be secured either within a cabinet or by allowing access to the room to be locked by staff. The facility is not yet ready to be licensed, but will be once the items have been successfully corrected. LPA conducted the Component III orientation with the prospective licensee during the visit. An exit interview and a copy of the report were provided at the time of the exit.the state’s words, verbatim · CDSS document, Apr 12, 2022

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Mesdjian, Liza (Administrator & Corporate Board Member) Interview Method: Telephone interview On 2/17/22, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Feb 17, 2022