A Loving and Joyful Home RCFE

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/1/23 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator stated that they would be available by phone if needed arrived to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 6 resident bedrooms, 3 bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA advised that a new facility sketch be submitted to reflect that Rm 4 is a resident room and Rm 5 is a staff room. LPA reviewed 6 resident files. An advisory was issued to insure LIC 602s are accurate for resident conditions and that LIC625s are done annually, including reflecting resident participation. LPA reviewed 2 staff files. LPA advised that documentation of training contains dates of when training occurred. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Nov 1, 2023

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

Type of visit: POC

On 9/20/23, LPA Mknelly conducted a plan of correction visit and met with Anita Heydon. Citations issued on 8/15/23 were confirmed to have been cleared. The home is observed to be clean, safe and resident's needs met. No deficiencies are noted in this visit. Report reviewed and copy provided.the state’s words, verbatim · CDSS document, Sep 20, 2023

Allegation investigated: Staff are not background cleared to care and supervise residents in care.

On 8/15/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke with Caregiver to deliver complaint findings for the above allegation. Administrator, Anita Heydon, arrived for the report review. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Records review found that S1, S3, S4, S5 and S6 are not associated to the facility. Administrator stated that they are experiencing difficulties accessing the Guardian system. S1 is considered by the Administrator to be a volunteer who does not do resident care. However, statements provided found that S1 does assist with care at times and is unsupervised with residents at times. Regardless, Volunteers are required to obtain a criminal record clearance before presence in the facility. S1 was associated to this home on 8/8/23. S3 has no record of fingerprint clearance. S3 worked at this home for approximately seven months. S4 had no known prior clearance before 8/5/23 and is “in process”. S5 criminal record clearance found their last clearance was in 1997. Report continued... Substantiated LPA discussed with Administrator that as they are aware of the need for criminal records clearance before staff are present at the facility, they could have discussed their challenges with Guardian and use of paper transfer request forms. In addition to citations issued, civil penalties are to be applied. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Anita Heydon. Copy of this report, civil penalties and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 15, 2023 · control 59-AS-20230728115741

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(b)(1)(D) · Plan of correction due date: Aug 16, 2023

Criminal Record Clearance (b) In addition to the applicant, the provisions of this section shall apply to criminal convictions of the following persons: (1) (D) Any staff person, volunteer, or employee who has contact with the clients. this requirement was not met based on interviews and records reviews that found 5 of 6 staff were not criminal record cleared and or associated to this home. This posed an immediate risk to residents.the state’s words, verbatim · CDSS document, Aug 15, 2023

Plan of correction: Staff either no longer work at the home or have been criminal record cleared since this investigation was conducted. Licensee will attend and submit proof of attendence of staff Administrator retraining for Criminla record clearance. By the POC date of 8/16/23 licensee will submit proof of a scheduled training within 7 days.

Allegation investigated: Facility is over capacity

On 8/15/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Anita Haydon, Administrator, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. LPA found that by having 6 residents and the Administrators family member residing at the home and receiving care from caregivers also, the facility was over their fire clearance capacity of 6 residents. On 8/4/23, R1 was in process of moving from the facility. Licensee will continue to include family member, R4, as a resident as long as R4 resides at the facility and receives care from caregivers. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Anita Heydon . Copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 15, 2023 · control 59-AS-20230727143011

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Aug 16, 2023

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 requirement was not met based on records and interviews finding facility over 6 resident capacity. This posed an immediate risk to residents. Civil penalties applythe state’s words, verbatim · CDSS document, Aug 15, 2023

Plan of correction: Licensee is now in compliance as a resident moved out. Licensee will sunmit a statement of understanding of this requirement by the POC date of 8/16/23.

Type of visit: Case Management - Deficiencies

On 8/15/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator. During the course of investigating complaint numbers 59-AS-20230727143011 and 59-AS-20230728115741, LPA found additional violations not previously alleged. Review of medications on 8/4/23 found daily medications to be administered in a kitchen drawer which was not locked. Additionally, the medication closet contained prescription and over the counter medications of past residents and some "house supply". Four of the medications or supplements were past their expiration date. Additionally 5 staff files were found to be missing required employee records and or proof of training. 3 of the employees are no longer working at the facility. The other two staff files are in process of correction. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Aug 15, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Aug 16, 2023

Incidental Medical and Dental Care(h)(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 based on observation that medications were not safely stored or disposed of when expired. This posed an immediate risk to residents.the state’s words, verbatim · CDSS document, Aug 15, 2023

Plan of correction: Licensee will submit a plan for locked storage of medications, auditing medications for expiration dates and destruction of medications when discontinued or resident moves out by the POC date of 8/16/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Sep 15, 2023

Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met in review of 5 of 7 employee files. This posed a potential risk to residents.the state’s words, verbatim · CDSS document, Aug 15, 2023

Plan of correction: Licensee will bring all current employee files to compliance for required documents and training by the POC date of 9/15/23. To be cleared by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/20/22 to conduct a Annual Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required Department COVID-19 testing protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. Administrator was present to assist with the visit. LPA toured the interior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA advised water temperature issues be resolved with warning sign at the kitchen sink, Knife drawer latch be repaired, and record of fire drills be maintained at the home. LPA and caregiver completed the infection control domain and facility was found to be in substantial compliance at this time. LPA advised that Infection Control Plan due 6/30/22 is late. Licensee shall submit their plan for approval before 60 days from today. Records review was conducted. LPA advised licensee discuss issues of special diets and dementia diagnosis in 602 be clarified with physicians and that Catheter training be documented in employee files. Licensee will submit: LIC 500 staff roster, LIC 9020 resident roster and liability insurance certificate for 2022-2023. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Oct 20, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility today and met with the Administrator, Anita, to follow-up on a incident report received on 5/13/22. Facility currently does not have any COVID-19 positive cases. LPA wore N-95 masks and were screened by facility upon entry. Facility staff wore masks in the care home. The incident involved R1 leaving without assistance on 5/6/22. R1 left the home without assistance to an area convenience store. R1 was found by caregiver and returned to the facility. During today’s visit, LPA interviewed staff and and resident and reviewed resident records. Resident and representative are currently seeking an updated 602 that more accurately describes their recovered condition. In addition to the updated 602, licensee will hold a care conference with the resident and update their care plan. While LPA was present, Fire doors were found propped with door stops. Stops were removed and alternatives were discussed. Technical violation notice provided. No deficiencies are cited at this time. Exit interview conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, May 16, 2022

Allegation investigated: Facility is refusing to take resident back

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 3/22/22 to provide complaint findings. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival LPA completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPAs reviewed resident records, facility records and conducted interviews. The department finds that facility met Tittle 22 requirements. Resident returned to the facility when licensee set up Covid care staffing for the resident. This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and report provided. Unfoundedthe state’s words, verbatim · CDSS document, Mar 22, 2022 · control 25-AS-20220106080402

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility staff threw water onto resident Facility staff speaks and treats residents in a disrespectful manner Facility staff failed to properly notify family concerning a residents hospital visit/admission

On 12/16/21, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Licensee of facility. The reason for the visit was to deliver findings for the allegation sited above. Upon entering the facility, analyst spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore a surgical mask and maintained distance during the visit. LPA reviewed staff and resident records and conducted extensive interviews. LPA finds that the allegation cited above are Unsubstantiated. Neither residents nor staff coroborated that Licensee was disrespectful to or threw water at a resident. Licensee stated that she always notified families of resident hospitalizations. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 22, 2022 · control 25-AS-20211228145848

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/12/21 to conduct a Post Licensing Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.Administrator was present to assist with the visit. LPA toured the interior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and caregiver completed the infection control domain and facility was found to be in substantial compliance at this time. LPA advised the following: Documentation of staff training and CPR be maintained at the home, that a posting is in place for faucets exceeding 120' F. and that documentation and recording of special diets be maintained. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Oct 12, 2021

The state marks this report as 4 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Licensee engaged in a verbal altercation in the presence of residents. Licensee is providing care and supervision to a relative who resides in the home.

On 9/9/21 at 2:00 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with caregiver. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by caregiver. LPA conducted records review and interviews. LPA is unable to find and or meet the preponderance, per policy. Licensee acknowledged that they and a family member occasionally have animated conversations yet stated that they are sure to have those conversations away from other residents. Others who were interviewed did not report witnessing or being disturbed by the licensee and family interactions. Report continued. Unsubstantiated While the licensee does provide as needed assistance to a family member when that family member is at the facility, the licensee has not exceeded the facility's capacity and there was no evidence found that the assistance provided to the family member effects the care provided to residents. There are circumstances that warrant further discuss with the licensee and CCL. An office meeting is to be scheduled to discuss this issue further. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and report copy provided.the state’s words, verbatim · CDSS document, Sep 9, 2021 · control 25-AS-20210714120704

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/13/21 to conduct a Post Licensing Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was partially screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. LPA spoke with Licensee by phone. Licensee/ Administrator arrived to assist with the visit. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and caregiver completed the infection control domain and facility was found to be in substantial compliance at this time. LPA advised the following: Visitor screening be more robust (temperatures and symptoms recorded), provided a sign in symptom screening form for daily records of all residents, staff and visitors, PINs 21-10, 21-17.1, 21-32.1 and 21-37 were provided. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Aug 13, 2021