Cresencia Care Home

Allegation investigated: Questionable death. Staff administered oxygen without a Dr. order.

Licensing Program Analyst (LPA) Ryan Gardner scheduled an office visit to deliver findings for the above complaint allegations. LPA met with Administrator Restituto Calilung and explained the reason for the visit. During today’s visit, LPA conducted interviews with staff, and reviewed, and was provided facility documents. For allegation, Questionable death: During document review, LPA discovered that Resident R1 was on hospice and passed away at the facility on June 8, 2020. R1’s death certificate did not have any suspicious concerns. R1’s death certificate listed the cause of death with multiple serious medical conditions. Unsubstantiated During interviews with staff, staff S1 stated that during resident checks on the morning of June 8, 2020, R1 did not look well, and was pale in the face. S1 immediately checked R1’s oxygen level and vitals, and was concerned due to low levels. S1 called the Administrator to inform them that R1 was declining and had a change of condition. The Administrator informed S1 to give R1 oxygen as comfort care per R1’s hospice order for oxygen. S1 immediately called hospice, and hospice informed S1 that they were on the way to the facility. While S1 was calling hospice, the Administrator called R1’s family to inform them of R1’s change of condition. When the hospice nurse arrived at the facility, R1 had already passed, and was officially pronounced deceased upon arrival. For allegation, Staff administered oxygen without a Dr. order: During document review, LPA discovered that R1 had a doctor’s order for Oxygen from the hospice doctor dated April 4, 2020. LPA also discovered that the Administrator and S1 had Oxygen Safety Training completed on December 13, 2019, by a Registered Nurse from a hospice company. Additionally, S1 had a second Oxygen Safety Training and Education completed on April 8, 2020. Based on the evidence gathered during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided Administrator Restituto Calilung, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Feb 9, 2023 · control 18-AS-20200713160712

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the front door and at the entry point. There is one entry point designated where sign in procedures and screening occur. The staff are symptom/temperature screening visitors upon entry into the facility. LPA observes that all staff are wearing face masks. LPA is informed that there are no positive cases of Covid-19 at this time. There are five (5) residents present at the time of the visit, of which four (4) are receiving hospice services. LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and a 30 day supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in infection control. The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms. Emergency food supply is in place. LPA inquired about fit testing and found that the employees have not been fit tested for N95 respirators. Technical assistance provided during this visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.the state’s words, verbatim · CDSS document, Sep 8, 2022

The state marks this report as 2 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) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with licensee/administrator Restituto Calilung and advised him of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. LPA went over COVID-19 best practices for infection control and prevention with Mr. Calilung who is successfully incorporating the facility's Mitigation Plan. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA advised that paper towels should on a holder or stand. LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated. LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. LPA observed a storage area for storing all PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to residents. LPA and Mr,Calilung discussed creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put inside and outside of an isolation room. LPA inquired as to if staff have been fit tested for N95 masks, and Mr. Calilung stated his staff have not been fit tested yet. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, residents have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA provided Mr. Calilung with the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. An exit interview was conducted, and this report was discussed and provided to Mr. Calilung along with a copy of PIN 21-10-ASC and LIC9102 TA Advisory Note.the state’s words, verbatim · CDSS document, Aug 12, 2021