Terra Lago Assisted Living

Type of visit: Required - 1 Year

On 10/31/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Staff, Saif Ali Choudry, who was informed of the purpose of the visit. LPA spoke with Administrator Sahar Choudry during the visit, At the time of the visit there was (1) staff and (5) resident present. The facility is a one story home with attached garage. No firearms or pools are present at the facility. The home has (4) bedrooms and (3) bathrooms. The residents served are elderly adults ages 60 years and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following: Infection Control: The LPA observed hand washing stations with hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train staff on infection control guidelines. Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide were operational, and the hot water temperature was recorded at 106.5F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Record Review and Resident/Staff Files: LPA reviewed staff files and training. All staff have criminal clearance. During the visit the one (2) staff at the facility had CPR training which was expired.The administrator re-certification was verified as being submitted, however the Administrator and Assistant- administrator do not have documented training for review during the time of the visit. Deficiency was cited for staff records and plan of correction was created with administrator. Resident files were reviewed all of which posessed required documents. Health Related Services/ Incidental Medical Services: All client medication was locked in kitchen pantry. LPA reviewed resident medications, all of which were accounted for. One medication, M1 for Resident 1 (R1) did not have a current doctors order at the facility. The administrator was able to provide documentation by the end of the visit. A technical advisory note was documented for all resident medication records to be updated. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Technical noted was documented for facility to update this to the current department requirements. The last fire drill was conducted April 2023. Deficiency was cited and administrator stated they would conduct Fire Drill by the end of the business day 10/31/23. An exit interview was conducted where a copy of this report along with deficiency, technical notes and appeal rights were reviewed and provided to Staff, Saif Ali Choudry.the state’s words, verbatim · CDSS document, Oct 31, 2023

Allegation investigated: Resident was left in a soiled diaper for a long period of time.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation listed above. LPA George met with Saif Choudry,Caregiver and LPA informed of the purpose of the visit and the elements of the allegation. The allegation was investigated and consisted of observation, interviews and record review. Regarding the allegation of resident was left in a soiled diaper for a long period of time. It was reported that on or around March 20, 2023, Resident #1 (R1) reported that they needed their diaper changed. At the time of the incident the facility had a census of 4 residents and 1 staff working. The facility has a live in caregiver that is expected to assist when the resident has a need. Per an interview with R1 stated that they did not know how to alert staff, and that they had called out to staff for help, however there was no response. R1 believes that they had been waiting for maybe an hour. LPA conducted a review of records (social media post), that was made at 3:59am revealed R1 did in fact make an attempt to contact staff and there was no response. ***Continued on 9099C. Substantiated Per the Administrator Sahir states that S1 changed R1’s diaper at 4:45am, this information was confirmed, and revealed that R1 waited for 46 minutes. The facility is not equipped with a call system and relies on sound monitors to alert staff that a resident is in need of assistance. The sound monitor is centrally located in the hallway sitting on the to of the cabinet, and is in the middle of all the resident bedrooms. S1 states that the residents are checked every hour. Based on interviews and record review the allegation of resident was left in a soiled diaper for a long period of time is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8), on the attached 9099D. An exit interview was conducted and a copy of this report 9099C, 9099D and appeal rights were provided to Saif Choudry. Facility denied Law enforcement access to enter the facility. Regarding the allegation facility denied law enforcement access to enter the facility. It was alleged that on or around March 21, 2023, staff #1 (S1) prevented Resident #2 (R2) from hitting R1. R2 is reported by facility staff as them being known to wander throughout the facility and into other resident rooms. R2 also likes to lay down on an empty bed located inside of R1’s bedroom. A review of records revealed that S1 had allegedly prevented S2 from hitting R1, however S1 denied that the alleged incident occurred. R1 had expressed that they were afraid of R2 since they had allegedly tried to hit them. As a result report law enforcement was contacted and responded to the facility. However, there was no evidence to corroborate that law enforcement being denied entry. Therefore, the allegation facility denied Law enforcement access to enter the facility is UNFOUNDED. A finding that the complaint is unfounded means 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 Saif Choiudry, Caregiver.the state’s words, verbatim · CDSS document, Jul 18, 2023 · control 18-AS-20230327120802

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 1, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on observation and interviews this requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Jul 18, 2023

Plan of correction: The licensee failed to ensure that 1 out of 1 times R1 was given the care and supervision based on their needs. This poses a potential health safety and personal rights risk to persons in care. The licensee agrees to an inservice incontinent care, when to peform checks and change the residents. Proof of the completed POC is due by 5pm on 08/01/2023.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Caregiver, Tania Montano who was informed of the purpose of the visit. At the time of visit there was 1 staff and 3 residents present. The facility currently has zero positive or suspected Covid-19 cases. During today's visit, LPA toured the facility inside and out with Tania and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels) in all restrooms. LPA did not observe any pools or bodies of water within the premises. LPA was informed that no weapons or ammunition is maintained at the home. No annual fees due. The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed via telephone with Administrator, Saher Choudry who authorized Tania Montano to sign this report. A copy of this report was provided to Tania Montano.the state’s words, verbatim · CDSS document, Oct 10, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 1:20 PM, LPA was met by caregiver Alisaif Choudry and explained the purpose of the visit. Present in the facility during time of visit were one (1) staff as well as four (4) residents. Staff and residents are fully vaccinated. There are currently no cases of COVID-19 within the facility. During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed proper signage throughout the facility, insufficient hand hygiene supplies, insufficient cleaning and disinfecting provisions, and proper use of face coverings by staff. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, PPE supplies are insufficient, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor resident(s) regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 18, 2021