Busman Residential Care

Allegation investigated: Staff caused injury to resident Staff handled resident in a rough manner

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of delivering findings on the complaint with the above allegation. LPA Colvin met with Administrator John Reade and advised them of the purpose of today's visit. Below is a summary of the findings discussed: Regarding allegation "Staff caused injury to resident": Department staff conducted interviews with staff and reviewed facility file and hospice paperwork for Resident #1 (R1). Record review and interviews revealed that R1 requires maximum assistance with all activities of daily living (ADLs), which includes assistance with transferring. Hospice records show only a bruise to R1’s arm, first observed on October 2, 2020. LPA Colvin additionally verified that R1 was taking prescribed blood thinning medication twice daily, which according to hospice notes, could potentially cause the resident to bruise more easily. LPA Colvin was unable to interview R1 due to R1 passing away while the investigation was still open. There is insufficient evidence to support the claim of physical abuse, and therefore, the allegation “Staff caused injury to resident” is UNSUBSTANTIATED. . Unsubstantiated Regarding allegation "Staff handled resident in a rough manner": Department staff conducted interviews with staff and reviewed facility file and hospice paperwork for Resident 1 (R1). The complaint allegation was specific to Staff 1 (S1), but interviews conducted with facility staff deny S1 ever working at the facility. LPA Colvin observed that S1 is associated to the facility and pulled a contact number for them from the Guardian System. LPA Colvin was unsuccessful in getting a hold of S1 through the number available, and similarly, LPA Colvin was unable to interview R1 due to R1 passing away during this investigation. Therefore, due to lack of evidence to support the claim, the allegation “Staff handled resident in a rough manner” is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with Administrator John Reade and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 29, 2022 · control 18-AS-20201112124219

Allegation investigated: Facility staff violate residents personal rights

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of following up on the complaint with the above allegation. LPA Colvin met with Administrator John Reade and advised them of the purpose of today's visit. Below is a summary of the findings discussed: Regarding allegation "Facility staff violate residents personal rights": Department staff previously interviewed staff related to the allegation. During today's inspection, LPA Colvin interviewed 4 of 5 current residents (one was asleep), as well as attempted to interview family of a deceased resident via telephone. LPA Colvin did not obtain any additional evidence today through interviews that would support the allegation, as the claim was either denied or the answers provided in interviews was inconsistent. Therefore, due to lack of evidence to support the claim, the allegation "Staff member was physically abusive to resident in care." is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with Administrator John Reade and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 29, 2022 · control 18-AS-20210831165539

Allegation investigated: Staff member was physically abusive to resident in care.

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of following up on the complaint with the above allegation. LPA Colvin met with Administrator John Reade and advised them of the purpose of today's visit. Below is a summary of the findings discussed: Regarding allegation "Staff member was physically abusive to resident in care": Department staff previously interviewed staff and residents related to the allegation. All interviews conducted during initial investigation conceeded that there was no abuse ocurring at the facility. During today's inspection, LPA Colvin interviewed 4 of 5 current residents (one was asleep), as well as attempted to interview family of a deceased resident via telephone. LPA Colvin did not obtain any additional evidence today through interviews that would support the allegation, as the claim was either denied or the answers provided in interviews was inconsistent. Therefore, due to lack of evidence to support the claim, the allegation "Staff member was physically abusive to resident in care." is UNSUBSTANTIATED. Unsubstantiated A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with Administrator John Reade and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 29, 2022 · control 18-AS-20210820142432

Allegation investigated: Resident's were left unattended.

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of delivering findings on the complaint with the above allegation. LPA Colvin met with Administrator John Reade and advised them of the purpose of today's visit. Below is a summary of the findings discussed: Regarding allegation "Resident's were left unattended": The Department conducted interviews with staff, residents, and other persons who witnessed the above allegation. While Licensee John Reade denied the allegation and stated that he was present in the backyard of the facility on 3/31/21, other statements obtained contradict this information. Other statements obtained through interviews relay that either John and his wife were out of town in Tijuana during the date this took place, or that Licensee John was next-door at an unlicensed location. In all statements obtained, including that of Licensee John, all persons agree that someone by the name of "Mark" was present inside the facility. Statements from Licensee John changed regarding "Mark"'s relationship to the facility (employee versus someone helping with cooking) and Licensee never provided LPAs with contact information or full name of "Mark" for further investigation Substantiated LPAs additionally addressed with Licensee that there was no one by the name of "Mark" associated to the facility at the time of the investigation, and Licensee did not have an employee file for this individual. Therefore, since statements agree that "Mark" was the only person other than residents inside the facility on 3/31/21, and the majority of interviews state that there were no other persons besides residents present at facility while "Mark" was there, and there are no employee documents for "Mark", the allegation "Resident's were left unattended" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. This deficiency is regarded in Health & Safety Code as a serious deficiency which results in an immediate civil penalty of $500, which LPA Colvin will be assessing today. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, LIC421IM, and appeal rights were provided to Administrator John Reade during the exit interview.the state’s words, verbatim · CDSS document, Nov 29, 2022 · control 18-AS-20210402150356

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80065(A) · Plan of correction due date: Nov 30, 2022

Personnel Requirements: (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by: Based on interviews, the Licensee did not comply with the above regulation on at least one date. Interviews support that on 3/31/21, residents were left alone in the facility with a non-staff member named "Mark". No person named "Mark" was associated to facility. This was an immediate safety risk to all residents.the state’s words, verbatim · CDSS document, Nov 29, 2022

Plan of correction: Licensee agrees to review Title 22 Regulation section regarding Personnel Requirements (80065) as well as Criminal Record Clearance (80019) and provide LPA Colvin with statement of understanding regarding requirements for all adults and staff who enter the facility. Due by Plan of Correction date of 11/30/22.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit in order to conduct a health and safety check. LPA met with administrator John Reade, who was informed of the purpose of the visit. At the time of the visit there were (2) staff and (5) residents present. LPA proceed to conduct a walk through of the facility. LPA observed that the home was being painted from the outside, and did not observed any active construction in the interior of the home. LPA spoke with administrator who confirmed this, and stated that the home would be painted for the next (3) days. LPA was informed (1) resident was at the hospital during the visit whom had a doctor's appointment. LPA proceeded to observe the facility medications cart and the central entry point. LPA had her temperature taken upon arrival to the facility. LPA walked through the resident rooms and observed the (5) resident, (3) were in the upstairs family room watching tv and reading magazines. (1) resident was seated at the dining table, and (1) resident was in their room. LPA requested staff file for the administrator and the administrator was unable to provide it at the time of the visit. This will be documented on deficiency page along with the plan of correction. LPA requested resident files, which administrator was unable to provide at the time of the visit. This deficiency will be documented along with the plan of correction. LPA requested the most up to date copy of the LIC500 and LIC9020. Administrator stated that he had these documents but was unable to access it as it was in the facility garage and could not be accessed in a timely manner . This deficiency will be documented along with plan of correction. An exit interview was conducted where a copy of this report along with LIC 809-D pages and appeal rights were reviewed and provided to administrator, John Reade.the state’s words, verbatim · CDSS document, Oct 25, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(f) · Plan of correction due date: Nov 4, 2022

87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours... This requirment was not met as evidenced by: Based on interview LPA was informed by administrator that the documentation for staff and himself where in the fcaility garage and he would not be able to access it in a timely manner. Therefore, LPA was unable to review and collect documentation at the time of the visit. This poses a potential health, saftey, or personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: Licensee will ensure that staff files are in an accessible area of the fcaility at all times. Licensee will aquire filing cabinets and show photo evidence of this to LPA by the POC date. The licensee will also send the LPA the documentation that was unable to be provided during the time of the visit by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(d) · Plan of correction due date: Nov 4, 2022

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours... This requiremnt was not met as evidenced by: Based on interview with administrator, the resident files were unable to be provided in a timely manner. Therefore, the LPA was unable to review these documents during the time of the visit. This poses a potential heath, saftey, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: Licensee will ensure that resident files are made accessibel at all time in the facility. Licensee will provide phot proff of the new accessibel site of the resident files, and provide LPA the documents requested by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87508(b) · Plan of correction due date: Nov 4, 2022

87508 Register of Residents (b) Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours... This requirment was not met as evidenced by: Based on interview with administrator who stated the register was located in the facility garage and could not be accessed in a timely manner. This poses a potential health, saftey, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: Licensee will send LPA the most up to date record by POC due date, and send LPA phot proff of where this records will be placed for easy access.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(e) · Plan of correction due date: Nov 4, 2022

87412 Personnel Records (e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. This requirment was not met as evidenced by: Based on interview with administrator, LPA was informed that the staff scheduleLIC500 could not be accessed in a timely manner as this document was amoung others in facility file boxes in the facility garage. This poses a potential health, saftey, or persinal rights risk for residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: Licensee will send the LPA the most up to date version of the LIC500 by the POC due date, as well as a photo of where this document will be stored for easy access.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by S1 and met with Licensee John Reade, who was informed of the purpose of the visit. At the time of visit there were 3 staff and 5 residents present. The facility currently has zero positive or suspected Covid-19 cases. During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility and advised licensee to post them throughout the facility. A single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. LPA advised licensee to start documenting these temperatures and to have a sign in sheet for visitors. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. LPA advised licensee to place soap in down stairs bathroom. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. LPA advised Licensee to have staff FIT tested for the N95 masks. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces. During the tour of the facility LPA reviewed LIC9020 and advised Licensee to update this after R1 passed away. LPA received a copy of the death report that was e-mailed the the department within 7 days. LPA also advised Licensee to e-mail updated LIC500 as soon as possible. LPA was able to review e-mail from Administration Certification department for Administrator Certification renewal. LPA spoke with Department representative Roshika, and confirmed this information. There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to facility licensee, John Reade.the state’s words, verbatim · CDSS document, May 16, 2022

The state marks this report as 7 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.