Keen Home Harvard

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit to the facility to complete the Annual Required inspection. At approximately 1:00 PM, LPA Tea was greeted and granted entry by Administrator (AD) Latoya Johnson and the purpose of the visit was explained. The facility is licensed for a capacity of six residents, including one non-ambulatory and five bedridden residents, with a hospice waiver for six. At the time of the visit, there were six residents in care, there were no residents receiving hospice services. LPA Tea reviewed six resident files and two staff files. All files contained the required documentation. The Administrator’s Certificate is current and expires on December 21, 2026. LPA Tea, accompanied by care staff, toured the facility. The physical plant, food service areas, and first aid kit were inspected. The facility consists of six resident bedrooms, five full bathrooms, a staff medication room, living room, kitchen, dining area, and an attached garage. Smoke detectors and carbon monoxide detectors were observed in common areas and bedrooms and were operational. Resident bedrooms were appropriately furnished with required furniture, adequate bed linens, and sufficient closet and drawer space to meet residents’ needs. Bathrooms were inspected and found to be clean and in good repair. Toilets and faucets were operational, grab bars were securely installed, and showers were free of mold and mildew. Water temperature measured approximately 116.9°F. An adequate supply of towels, toiletries, and personal hygiene items was available. Common areas were clean, organized, and free of hazards, with unobstructed walkways and exits. The first aid kit was fully stocked with required supplies, including dressings, bandages, tweezers, a thermometer, (Annual inspection report continued on LIC809C) and scissors. The kitchen was inspected, and an adequate supply of perishable and non-perishable food was observed. Kitchen appliances were operational at the time of the visit. Sharps were secured in a locked kitchen cabinet. Toxic substances were observed to be locked and inaccessible to residents in areas including beneath the kitchen sink and in the garage. Fire extinguishers throughout the facility were fully charged. The most recent fire drill was conducted on April 16, 2026. Emergency food and water supplies were observed to be adequately stocked in the garage. Outdoor areas were also inspected. The backyard provides ample shaded seating for residents, and a barbecue grill is available for use. The exit gate on the right side of the home was observed to be self-latching and operational. The facility provides activities tailored to residents’ preferences, abilities, and health conditions. Activities include games such as Jenga, arts and crafts, puzzles, walking, light exercise, and gardening. At the time of the visit, residents were observed watching television and participating in leisure activities. LPA reviewed medication storage and administration practices. Medications are stored in a locked cart within the staff medication room and are administered in accordance with physician orders. LPA interviewed residents regarding their quality of care and spoke with staff regarding services provided. Based on observations made during today’s inspection, no deficiencies were cited in the areas reviewed in accordance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Latoya Johnson. A copy of this report LIC 809, along with LIC 809-C, LIC 858, and LIC 859, was reviewed and provided to the facility. The LPA also provided the facility with a Legionnaires’ Disease Fact Sheet for informational and preventive purposes.the state’s words, verbatim · CDSS document, May 12, 2026

Allegation investigated: Staff did not notify resident's responsible party of incident in a timely manner.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met with Administrator Latoya Johnson and explained the reason for the visit. The investigation into the allegation, staff did not notify resident's responsible party of incident in a timely manner, revealed the following. It was reported that after Resident 1 (R1) fell on June 16, 2024 the responsible party/power of attorney (POA) was not notified by facility staff until 4 to 5 hours after the fall. According to the incident report submitted to the Agency (Community Care Licensing) on June 17, 2024, R1 fell around 4:00 am on June 16, 2024. Staff called 911 and R1 was transported to the hospital, treated and returned to the facility the same day around 7:00 am. The Licensee reported that they were immediately called by Staff 1 (S1) after they called 911 and they (Licensee) called R1's responsible party/power of attorney (POA) to get permission to send R1 to the hospital. The POA agreed and R1 was transported to the hospital by paramedics. The Licensee reported that they contacted R1's responsible party/power of attorney (POA) around 10:00 am to inform them R1 had returned to the facility. R1's responsible party/power of attorney (POA) verified this report. Unfounded California Code of Regulation (CCR), Title 22, Division 6, 87211(a)(1) states, "A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below." Falling and being injured qualify under, CCR 87211(a)(1)(D), "Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." R1's responsible party/power of attorney (POA) verified they received a report and were called twice regarding this incident. R1's responsible party/power of attorney (POA) was notified the same day as the reported incident, therefore the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with the Administrator and a copy of the report was provided. S1 reported that paramedics arrived a few minutes later and transported R1 to the hospital. S1 reported that R1 returned to the facility around 7:00 am the same day. R1's responsible party/power of attorney reported they were notified right after the fall occurred and around 10:00 am after R1 returned to the facility. Staff 2 (S2) reported they arrived at the facility after the incident. S1 reported there were no other witnesses to the incident. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, resident sustained multiple falls resulting in injury while in care, revealed the following. R1 moved into the facility on April 22, 2024. R1 was diagnosed with Dementia, Coronary Artery Disease, Severe Arthritis and was non-ambulatory. R1 was identified as a fall risk when they moved into the facility. R1's care plan calls for R1 to be checked every 2 hours and to be assisted with all transfers and to be escorted whenever moving. R1 used a walker and a wheelchair. R1 suffered falls on May 10, 2024, May 12, 2024, June 16, 2024 and June 30, 2024. All incidents were reported to the Agency (Community Care Licensing) and R1's responsible party. Both falls in May 2024 resulted in no injuries and no report of pain or discomfort. R1 fell on June 16, 2024. Staff 1 (S1) was assisting R1 around 4:00 am and R1's knee gave out and both R1 and S1 fell. The walker hit R1 on their face causing an injury to their nose and bruising around their eyes. S1 called 911 and R1 was transported to the hospital, treated and released the same day. The Licensee scheduled an appointment for R1 with a medical professional on June 17, 2024 which resulted in R1 being treated for a urinary tract infection (UTI). R1 fell on June 30, 2024. S1 reported that around 4:00 am R1's bed alarm went off and they went to R1's room and R1 was found on the floor next to their bed. S1 reported that they called 911 because R1 reported pain. Paramedics arrived at the facility and assessed R1 and reported no injuries and reported there was no reason to transport R1 to the hospital. Staff 2 (S2) reported that X-rays were ordered on June 30, 2024 for R1 as a precaution and the results came back negative. After the fall on May 10, 2024, the facility ordered a pad to be placed next to R1's bed in case R1 fell out of bed. 3 out of 3 caregivers and the Licensee reported that R1 was given increased checks every hour after the fall on May 10, 2024. The Licensee reported that after the fall on May 12, 2024, a pressure alarm pad was placed on R1's bed to notify them if R1 was out of bed and R1 was encouraged to call for assistance using their pendant anytime they wanted help. After the fall on June 16, 2024, the facility consulted with R1's responsible party and their physician. R1 was prescribed a new bed that could be lowered close to the floor to help minimize falls. The bed did not arrive until July 2024. The Licensee reported they recommended a one on one caregiver to R1's responsible party after the fall on June 16, 2024 but they declined. The Licensee reported that they informed all staff that one caregiver should always be sitting next to or around R1 when they are awake. 3 out of 3 caregivers verified this information. R1's fall on June 30, 2024 happened around 4:00 am and staff was notified by the bed alarm and attempted to assist R1. The facility was constantly addressing R1's needs and adding preventative measures to mitigate R1's fall risk. There were no more falls reported for R1 after June 30, 2024. R1's responsible party reported that the facility did everything they could to prevent R1 from falling. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not address resident's change in condition, revealed the following. It was reported that R1's fall on June 16, 2024 was due to a change in condition, possibly due to their medication. Other than falling no details about the change in condition were provided. No details were provided as to which medication changes or specific medications contributed to R1 falling on June 16, 2024. 3 out of 3 caregivers and the Licensee reported that R1 had always had wandering behaviors, aggressive behaviors, refusing medications and was a fall risk since they moved in the facility on April 22, 2024. 3 out of 3 caregivers and the Licensee reported that R1 did not display any new behaviors in June or July 2024. A review of facility records show, after R1's fall on June 16, 2024, the Licensee scheduled a home health visit with a Nurse Practitioner on June 17, 2024. After the visit tests were conducted and R1 was diagnosed with a urinary tract infection (UTI). R1's physician ordered antibiotics to treat R1. After the fall the facility had R1 assessed by a medical professional who addressed R1's change in condition. There is no evidence to support the allegation therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 22-AS-20240729203119

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 1:00 PM, LPA Tea was greeted and granted entry into the facility by a caregiver staff and explained the reason for the visit. Administrator (AD) Latoya Johnson arrived shortly to assist with the visit. The facility is licensed for a capacity of six, one maybe non-ambulatory, and five maybe bedridden with a hospice waiver for six. Currently there are six residents, and there is one on hospice during today's visit. At 1:19 PM, LPA Tea reviewed six resident files and three staff files. Resident files and staff files contained all required documentation. The administrator certificate expires on December 21, 2026. LPA Tea along with care staff toured the facility at 2:13 PM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 6 resident bedrooms, 5 full bathrooms, medication staff room, living room, kitchen, dining area, and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 111.7 Fahrenheit degrees and 113.3 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps secured in a kitchen cabinet. LPA also observed toxin substances to be secured and locked and inaccessible to clients underneath the kitchen sink and garage. The fire extinguishers throughout Annual Inspection continued LIC809C the facility are fully charged. The facility’s last fire drill was conducted on February 18, 2025. Kitchen appliances are operational during today's visit. LPA observed emergency food and water supply in the garage. LPA toured the outside grounds and there is ample seating with shade. They also have a barbecue grill for grilling. The exit gate on the right side of the house is self-latching and operational. Facility provides activities based on resident’s personal preference and health condition and limitations. The residents love to play Jengga, do arts and crafts, play puzzles, some go out for walks and do exercise. There is someone that comes to the facility to conduct activities from time to time. Some residents like to tend to the garden in the backyard. At the time of the visit, LPA observed residents watching TV, going out for walks and sitting outside enjoying the nice weather. At 2:46 PM LPA reviewed medication storage and administration. Medications are stored in a locked cart in the medication staff room. Medications are being administered per physician order. LPA interview residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrator Latoya Johnson and a copy of this report LIC809, 809-C, LIC858, LIC859, was read and provided to the facility.the state’s words, verbatim · CDSS document, May 16, 2025