Rolling Green Senior Care

Allegation investigated: Staff did not ensure resident had a comfortable bed.

On July 7, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced and met with the Lead Caregiver. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegation. On April 13, 2023, LPA Venus Mixson initiated the complaint investigation. During the investigation, LPA Mixson and LPA Stephanie Martinez conducted interviews with the Administrator, Staff Members, and Residents. On April 11, 2023, Community Care Licensing (CCL), received information which stated staff did not ensure resident had a comfortable bed. It was reported that Resident's bed was unplugged which caused Resident's mattress to be deflated. Interviews revealed that there are no beds at the facility that can deflate. It was reported that one of the resident's bed was unplugged for a period of time, but the Resident was not in the bed during the time. Information obtained from Resident's who were directly affected, indicated that there were no concerns regarding their bedding. No issues or concerns regarding resident's bed was advised. Based on interviews and observation, this agency has investigated the allegation of staff did not ensure resident had a comfortable bed and we have found that the complaint was unfounded, meaning the allegation was false, could not have happened, or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted and a copy of the report, along with the LIC 811, was provided to the Lead Caregiver. Unfoundedthe state’s words, verbatim · CDSS document, Jul 7, 2023 · control 18-AS-20230411151529

Allegation investigated: Staff serve expired food to residents in care.

On July 7, 2023, Licensing Program Analyst (LPA), Venus Mixson conducted a visit to the facility and met with the Lead Caregiver. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegation. On April 13, 2023, LPA Venus Mixson initiated the complaint investigation. During the investigation, LPA Mixson and LPA Stephanie Martinez conducted interviews with the Administrator, Staff Members, and Residents. On April 11, 2023, Community Care Licensing (CCL), received information which stated staff serve expired food to residents in care. It was reported that expired meat and milk was served to residents. Information obtained from staff and residents indicated there is no known information of residents being served expired foods. On April 13, 2023 and June 6, 2023, the food supply was inspected by LPAs and no expired foods were observed. Based on interviews and observation, the allegations that staff serve expired food to residents may have occurred, however is not supported or proven by evidence. Therefore, the allegation is "UNSUBSTANTIATED" at this time. 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 and a copy of this report, along with the LIC 811, was provided to the Lead Caregiver. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 7, 2023 · control 18-AS-20230411151529

Type of visit: POC

Licensing Program Analyst (LPA) Javina George made an unannounced Plan of Care (POC) visit to confirm the whereabouts of Resident #1 (R1), as they were to return to the facility as apart of the plan of correction for complaint control # 18-AS-20230602124116. LPA was greeted and granted entry by Leocardia Ogolla, Caregiver. The administrator was available via telephone as they had a personal appointment, during the time of LPAs visit and was not able to come to the facility. LPA conducted a tour of the interior and the exterior of the facility, and observed the following deficiencies: LPA observed for Resident #1(R1) to not be at the facility and was informed that R1 was no longer at the facility. Department staff verified that R1 was at the hospital and that they are still ready to be discharged. The hospital staff reported that the Licensee Ms. Okoro is not engaging in attempts to discharge R1 back to the facility, as she is not accepting or returning their phone calls. Ms. Okoro confirmed that she has not picked up R1 from the hospital and claims that the window had not been repaired and that R1's bed was picked up by the insurance company, preventing from having R1 to return to the facility. Due to the POC not being corrected, the following deficiencies were not corrected by the POC due date of 6/7/23, nor at the time of LPAs visit. Civil Penalties are being assessed and will continue to accrue until correction has been submitted: Deficiency is being cited under Title 22 Regulation 87468.2. The POC was to accept R1 back at the facility by 6/7/23. In addition the Licensee was to work with the hospital to ensure that R1 was returned to the facility. Civil penalties are being assessed for the dates of 06/07/2023 to 06/09/2023 in the amount of $100 per day covering the notes days, for a total of $200.00. Civil penalties will continue to accrue at the rate of $100 a day until proof of POC, is submitted. -Department staff conducted an interview with the Ms. Okoro in regards to R1 returning to the facility. Per Ms. Okoro the POC was met as R1 was admitted to another facility, as she was contacted by another facility regarding R1. The department contacted the other facility and learned that R1 was not admitted and had not reported that they were admitting R1 to the facility. Department staff verified that R1 was still at the hospital. As a result the department was provided with false and misleading statements by the licensee Ms. Okoro, and is therefore being cited for false claims. -During the tour of the physical plant LPA observed for a double pane window in the master bedroom to be broken withe several sharp, and jagged pieces to be sticking out for both residents and staff to be cut and or injured. The window was reported to have been broken on 5/31/23. Ms. Okoro placed Resident #2 (R2) inside the room. R2 is able to ambulate with a walker, the broken window poses an immediate heath and safety concern. Deficiency cited. -LPA observed for all three (3) resident bedrooms to have camera's located in each corner above the bedroom doors. LPA explained that any form of video surveillance needs to be approved, and to have cameras in the resident bedrooms was a violation of their personal rights as well as privacy. In addition the use of cameras is not included in the facility's plan of operation. LPA did not observe any signed consents from the residents or their responsible parties consenting to the use of video surveillance. Per the Licensee, Ms. Okoro the cameras are used as a safety measure to keep an eye on the residents as they are a fall risk. Deficiency cited. Based on today's visit, deficiencies were observed in the areas evaluated and cited according to California Code of Regulations, Title 22, Division 6 and listed on the 809D. An exit interview was conducted, and a copy of this report, 809D, and appeal rights were provided to Leocardia Ogolla, Caregiver.the state’s words, verbatim · CDSS document, Jun 9, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Jun 23, 2023

87207 False Claims No licencee, officer or employee nof a licensee shall make or dissemenate any false or misleading statement regarding the facility or any of the serives provided by the facility. This requirement is not met as evidenced by: 1 out of times the licensee stated that R1 was moving to another facility, and denied the hospital's phone calls, were to assist with a plan R1 back to the facility. This poses a potential heath, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 9, 2023

Plan of correction: The licensee agrees to make a personal statement of understanding about the importance of providing true and accurate information to the department, The statement is to include the potential risks and consquences of providing misleading/false claims, or statements. Proof is to be submitted to the department by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.2 · Plan of correction due date: Jun 23, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition.. residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy..the state’s words, verbatim · CDSS document, Jun 9, 2023

Plan of correction: The licensee agrees to have the cameras removed. The cameras were taken down at the conclusion of LPAs visit at approximately 2pm.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 10, 2023

Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observations, the Licensee did not ensure that 1 out of 1 time, the facility was in good repair, as the window was broken in the master bedroom on 5/31/23, leaving jagged and sharp edges exposed, to cut or injur anyone that comes in contact. This is an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 9, 2023

Plan of correction: The licensee agrees to have the window covered up with cardboard until the window can be repaired. In addtion, the licensee agrees to relocate R2 to another bedroom. Proof of correction is to be completed by 6/10/23 by 5pm.

Allegation investigated: Staff member is under the influence of a substance while providing care to residents. Staff do not provide adequate care to resident.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Administrator, Gertrude Okoro, and informed her of the purpose for her visit. The investigation included staff/resident interviews, records review, and records collection. The Department received a report alleging Staff One (S1) has consumed a narcotic in the presence of a resident in care. Staff and resident interviews reported having no knowledge of who S1 is. According to Administrator Okoro, no one by S1's name, has worked or resided in the facility. She reported no one by S1's name has visited the facility recently. Staff and resident interviews reported having no knowledge of any person being under the influence of any substance while in the facility. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. Unsubstantiated It was also alleged facility staff were not providing care to Resident One (R1). R1 was interviewed; however, refused to provide information regarding the matter. Staff interviews revealed R1 was provided assistance with Activities of Daily Living (ADLs) and staff notes revealed R1 would occasionally refuse some services. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. This report was reviewed with Administrator Okoro and a copy was provided. An exit interview was conducted; the Administrator reported she is unwilling to accept back R1 into the facility because the resident is a danger to staff and other residents in care. The LPA notified the Administrator a three-day eviction can be issued to R1, though approval would be required from the Department. This report was reviewed with Administrator Okoro and a copy, along with instructions on Appeal Rights, was provided.the state’s words, verbatim · CDSS document, Jun 6, 2023 · control 18-AS-20230602124116

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Jun 7, 2023

Additional Personal Rights of Residents in Privately Operated Facilities: (a)..residents in privately operated RCFEs shall have all of the following... rights: (20) To be protected from involuntary transfers, discharges, & evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted... & shall comply w/ all eviction & relocation protections...This requirement wasn't met as evidenced by: Based on interview the Licensee didn't ensure R1 was free from an involuntary transfer. Okoro admitted to refusing to allow R1 to return to the facility. This posed a threat to the H&S of R1.the state’s words, verbatim · CDSS document, Jun 6, 2023

Plan of correction: The Administrator stated she is refusing to accept R1 back into the facility. When asked for a plan of correction she requested the LPA adise on how to correct. The LPA informed the Administrator the facility has to accept R1 back and follow eviction procedures and properly transfer R1.

Type of visit: Office

On August 11, 2022, Licensing Program Manager (LPM) Jazmond Harris and Licensing Program Analyst (LPA), Venus Mixson met with Administrator, Gertrude Okoro at the Community Care Licensing Division (CCLD) Office located at 1650 Spruce Street, Suite # 200 in Riverside, CA. 92507. LPM and LPA explained the purpose of the meeting. The following was discussed in the meeting: The Riverside Regional Office received a Serious Incident Report (SIR) dated June 29, 2022 regarding a head injury to Resident #1. It was advised that Resident #1 fell and sustained a bruise, bump, and cut to the back of Resident #1's head. Facility staff contacted hospice care to advise of the incident, but did not contact emergency services for further evaluation. It was also reported that on July 21, 2022, Resident #2 fell and had bruising notated on the left orbital area. Facility staff did not indicate on the serious incident report that emergency medical services were contacted. Administrator denied medical services were contacted for the incident, due to no apparent imminent health concerns. LPM explained the importance of contacting emergency services for all head injuries. According to CCLD Regulations, 87465 (a)(1), Incidental Medical and Dental Care. This poses an immediate health and safety or personal rights risk to residents in care. Deficiencies will be cited. The Riverside Regional Office received a SIR regarding Resident #2 pertaining to an incident which occurred on July 14, 2022. It was reported that Resident #2 had a behavioral incident. Due to the behavioral incident, Administrator has increased supervision of the resident. No further concerns at this time. An exit interview was conducted, a copy of the report, along with the LIC 9099-d, 811, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 11, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 19, 2022

87465 (a)(1). Incidental Medical and Dental Care. The licensee shall arrange, for medical care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on record review and interviews, the Administrator did not contact emergency medical services for Resident #1 on 6/29/2022 and Resident #2 on July 21, 2022, regarding head injuries.the state’s words, verbatim · CDSS document, Aug 11, 2022

Plan of correction: Administrator states that the staff will be retrained on contacting emergency services and providing proper notification. Training documents will be provided. Administrator stated she will provide a written statement regarding her understanding of the regulation.

Type of visit: Case Management - Deficiencies

On August 1 2022, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a case management visit to address concerns regarding the facility reporting to Community Care Licensing (CCL) in a timely manner. LPA was greeted and granted entry by Administrator, Gertrude Okoro, introduced self, and explained the purpose of the visit. LPA met with Administrator and toured the facility for the purpose of conducting a Health & Safety inspection. No deficiencies were observed. LPA Mixson reviewed residents' files and pertinent documents were obtained. During this visit, LPA Mixson interviewed one staff. No residents were available for interviews. Staff interview revealed that on June 29, 2022, hospice staff was called for Resident #2 (R2). Hospice staff arrived and conducted an evaluation of R2. Pertinent documentation regarding the evaluation was obtained. Facility staff provided first aid. Facility staff did not report the incident to CCL until July 27, 2022. On July 27, 2022, the Regional Office was advised of an incident that occurred on July 14, 2022 regarding R4. The Murrieta Police Department and the Community Behavioral Health Assessment Team (CBAT), was called to the facility regarding R4's concerning behaviors. However, the facility did not report to CCL until July 27, 2022 which is a violation of Title 22 regulations. Deficiencies will be cited. An exit interview was conducted, and this report, along with the LIC 9099-D, LIC 811, and appeal rights were provided to Administrator.the state’s words, verbatim · CDSS document, Aug 1, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 8, 2022

87211(a)(1)(D) (a) Each licensee shall furnish a written report within 7 days of the occurrence of any event which threatens the welfare and safety of the resident. This requirement was not met as evidence by: The facility failed to report the incident to CCL within seven days.the state’s words, verbatim · CDSS document, Aug 1, 2022

Plan of correction: Administrator stated that the facility shall take immediate action if a future incident occurs. All staff will be trained on reporting to CCL in a timely manner. This will be completed by POC date. Training logs will be provided to LPA upon completion.

Allegation investigated: Staff member made inappropriate comments to resident and emotionally abused resident. Resident was left in bed for an excessive amount of time.

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Licensee/Administrator Gertrude "Trudy" Okoro. Below is a summary of the findings of this complaint: Regarding allegation "Staff member made inappropriate comments to resident and emotionally abused resident": LPA Colvin interviewed residents, staff, and other persons regarding the allegation. Interviews were inclonclusive regarding staff member's (S1) alleged inappropriate statements and emotional abuse towards resident(s). In an abundance of caution, Licensee/Administrator "Trudy" removed S1 from the scheudle on a temporary basis until a new resident that was clashing with S1 could adjust to living in a facility for the first time. According to all interviews, there is no longer any issue with S1, and all parties are comfortable with S1 returning to the facility. Unfortunately, LPA Colvin was unable to interview all residents (some sleeping) and S1, however, it is unlikely that these interviews would change the finings of this investigation. Unsubstantiated Based on interviews conducted and lack of any further evidence to support the claim, the allegation "Staff member made inappropriate comments to resident and emotionally abused resident" is UNSUBSTANTIATED. Regarding allegation "Resident was left in bed for an excessive amount of time": LPA Colvin interviewed residents and outside agencies who would have information relevant to the allegation. Additionally, LPA Colvin interviewed the reporting party, who clarified that the allegation included time that the residents were asleep overnight. LPA Colvin did not observe in interviews or record review any evidence that would suggest that resident(s) have been left in bed for an extended period of time, such as bedsores or pressure injuries. Therefore, due to lack of evidence, the allegation 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 Licensee/Administrator Gertrude "Trudy" Okoro and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 10, 2022 · control 18-AS-20220503084418

Type of visit: Case Management - Deficiencies

On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #18-AS-20220503084418. During today's inspection, LPA Colvin observed the following deficiencies: Accessible Chemicals: LPA Colvin observed the door for the laundry room and the garage to be propped open with a bottle of bleach. LPA Colvin observed other chemicals on the ground between the washing machine and dryer. Deficiency cited. Living Accommodations: During LPA Colvin's inspection of the facility. LPA Colvin observed that one of the resident bedrooms (the only single bed resident room) to not have a door. Instead, LPA Colvin observed a curtain hung up across the doorway to provide some element of privacy to the resident (R1). When LPA Colvin inquired about the missing door, Licensee/Administrator Gertrude "Trudy" Okoro stated that it was removed in order to be able to use a Hoyer Lift for the resident. Deficiency cited. Alterations to Building: During today's inspection, LPA Colvin observed a hidden office/bedroom adjoining the facility dining room. In this room, LPA Colvin observed a bed, which the Licensee/Administrator stated was used sometimes by her and sometimes by her husband. LPA Colvin inquired about when the changes were made to add this room, but the Licensee/Administrator was unsure. LPA Colvin requested a copy of the facility's building sketch, which was provided. LPA Colvin pointed out to the Licensee/Administrator that this room was not noted on the sketch, and therefore, must have come after the facility was licensed. There is also no note of the room in the Pre-Licensing inspection done on 11/28/18. Community Care Licensing (CCL) was not notified of the change and updated facility sketch was not provided to CCL to update the facility's file. Deficiency cited. LPA Colvin additionally inquired about if the facility obtained a building permit for the room . Licensee/Administrator was unsure if a building permit was obtained, and could not provide LPA Colvin with a copy of any permit. Deficiency cited. Due to observations made by LPA Colvin, the facility was cited and deficiencies are noted on the LIC809D page(s). LPA Colvin conducted an exit interview with Administrator/Licensee Gertrude "Trudy" Okoro, and a copy of this report, LIC809Ds, and appeal rights was provided.the state’s words, verbatim · CDSS document, May 10, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: May 11, 2022

Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above requirement with at least one area of the facility. LPA Colvin observed a bottle of bleach to be propping open the doors for the laundry room and garage. This is an imemdaite safety risk to residents in care.the state’s words, verbatim · CDSS document, May 10, 2022

Plan of correction: Licensee agrees to remove chemicals from accessiblity of residents. Licensee to tour facility and ensure all potentially hazardous chemicals are locked. Licensee may self-certifiy to LPA Colvin once complete.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87307(a)(2)(a) · Plan of correction due date: May 11, 2022

Personal...Services: (a)...shall be large enough to provide...privacy for the residents...(2) Resident bedrooms shall...at a minimum,...(A) ...be large enough to allow for easy passage between and comfortable usage of...other required items... and any resident assistant devices... This was not met by: Based on interviews and observations, the licensee did not comply with the above regulation with one resident. LPA Colvin observed that R1's bedroom is missing a door and only a curtain is hung to provide some privacy. Licensee states this is due to Hoyer Lift. This is an immedaite personal rights violation of R1.the state’s words, verbatim · CDSS document, May 10, 2022

Plan of correction: Licensee agrees to do one of the following: Move R1 to a larger room which will accomodate their medical equipment, OR replace the door on R1's room (can be another style of door which is less obstructive to equipment). Licensee to provide plan and proof of correction to LPA Colvin.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: May 24, 2022

Alterations to Existing Building or New Facilities: (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by: Based on interviews and lack of records, the Licensee did not comply with the above regulation with one room of the facility. LPA Colvin observed an addition to the facility (office/bedroom). Licensee states they do not have proof of building permit. This is a potential safety hazard to staff and residents.the state’s words, verbatim · CDSS document, May 10, 2022

Plan of correction: Licensee agrees to contact the City Planning Department to ensure the addition is on file and approved. Licensee to also contact County Code Enforecment to have the addition inspected for compliance. Licensee to provide LPA Colvin with approval from City and County agencies for the addition.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87208(a) · Plan of correction due date: May 24, 2022

Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation...Any significant changes...shall be submitted to the licensing agency for approval... This requirement was not met by: Based on observation and record review, the Licensee did not comply with the above regulation with one aspect of the Plan of Operation. LPA Colvin observed that the facility sketch did not include the added office/bedroom. This is a potential safety hazard to residents and staff.the state’s words, verbatim · CDSS document, May 10, 2022

Plan of correction: Licensee agrees to submit udpated Facility Sketch to LPA Colvin, which includes all buildings/rooms and their stated purpose. Plan of Correction due date is 5/24/22.

Allegation investigated: Medications are accessible to residents in care. Residents are not receiving assistance with incontinence needs. Staff do not respond to residents' call for assistance. Staff are not assisting residents' with hygiene needs. Facility does not provide meals of the quality and quantity to meet the needs of the residents. Facility is not disposing of expired or abandoned medications. Facility does not have adequate food supplies on hand. Refrigerated foods are not stored properly

Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to commence a complaint investigation as well as to deliver findings for the allegation(s) listed above. LPA was greeted and granted entry by Caregiver Traci Brown and explained the purpose of the visit and element of the allegation. The Administrator was unavailable to meet due to being out of the country. Medications are accessible to residents in care. At 12:43pm LPA observed the closet in the hallway that stores the residents medications to be unlocked. There is also a key hanging on the upper right-hand side on the outside of the door. One (1) of the three (3) residents are ambulatory and could access the medications. The allegation of Medications are accessible to residents in care is SUBSTANTIATED. ***Continued on 9099C Substantiated Residents are not receiving assistance with incontinence needs. Based on interviews conducted the allegation of Residents are not receiving assistance with incontinence needs is SUBSTANTIATED. Information provided that at the time of LPAs visit resident had not been assisted with being changed for the day and it was 1:32pm. LPA inquired about what happens during the night and feedback provided was that staff do not come to the resident bedrooms. Staff do not respond to residents' call for assistance. LPA conducted interviews the information provided was that during the night, staff are not responding to the bells when they are rung. Due to only one staff being on during the evening, and per the facility program plan the night staff is expected to be awake. However, it was reported that that during the evening staff are not responding when assistance is requested. Additionally, it was reported that staff are not making their rounds during the evening. Therefore, the allegation of Staff do not respond to residents' call for assistance is SUBSTANTIATED. Staff are not assisting residents' with hygiene needs. Staff reported that the residents are given their baths in the morning after they wake up and if there was an “accident” depending on the severity an additional bath is given. LPA conducted interviews and reviewed resident files two (2) of the three (3) residents are not receiving any outside services such as home health or hospice. It is solely the facility staff responsibility to assist residents with their hygiene needs. It was reported that there are no showers being given, not even bed baths, just a wipe down, and when it does happen it isnot thoroughly. It is important to note that the two non-ambulatory residents do need two staff to assist them, however there is only one staff on during the shift at a time. Based on the information provided the allegation of Staff are not assisting residents' with hygiene needs is SUBSTANTIATED. Facility does not provide meals of the quality and quantity to meet the needs of the residents. Information provided was that the food being served is old, rotten, and cold. LPA observed a container of Macaroni and Cheese that expired on December 4, 2021. During interviews conducted it was shared that the meals used to be complete and would be stored in the freezer and taken out for mealtimes, however due to the residents not liking the precooked meals, the meals were no longer precooked. LPA was informed that chicken is rarely served, that it is normally sandwiches and overall terrible. The allegation of Facility does not provide meals of the quality and quantity to meet the needs of the residents is SUBSTANTIATED. Facility does not have adequate food supplies on hand. At the time of LPAs visit there was a full deep freezer, a cabinet and refrigerator with food in the garage as well as a refrigerator inside of the kitchen. The supply was more than the 2 day supply of perishable and a 7 day supply of nonperishable food items. The vegetables (green onion, tomato) were fresh. However, In addition, food is reported to have been brought from the food bank, as well as staff are bringing food in with them from the store or fast food restaurants to ensure that the residents are being served complete meals. An example provided of if dinner is supposed to be grilled chicken then it would be grilled chicken, with mashed potatoes, but no veggies to accompany the main course. The allegation of Facility does not have adequate food supplies on hand is SUBSTANTIATED. Facility is not disposing of expired or abandoned medications. LPA observed five (5) maroon containers sitting in the corner on the inside of the living room that contained medications of previous residents. LPA inquired as to what the plan is for the medications, staff on duty did not know. Additionally, there were not any medication destruction records available for review. The allegation of Facility is not disposing of expired or abandoned medications is SUBSTANTIATED. Refrigerated foods are not stored properly. At 12:35pm LPA toured the kitchen and observed a bowl of potato salad and a bowl of peaches left uncovered inside of the refrigerator. Based on observation the allegation of Refrigerated foods are not stored properly 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. An exit interview was conducted and a copy of this report, 9099D and appeal rights was provided to Caregiver Traci Brown.the state’s words, verbatim · CDSS document, Dec 20, 2021 · control 18-AS-20211214124454

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(h)(2) · Plan of correction due date: Dec 21, 2021

Incidental Medical and Dental Care Services: Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees. LPA observed medication in staffs room to be accessible to clients and visitors. Based on observation this requirement is not met as evidenced by the closet being unlocked 1 out of 1 times. This poses an immediated health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licensee agrees to provide training to all staff on the importance of keeping all medications locked at all times when not in use. POC is due by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Jan 4, 2022

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. Based on observation the licensee did not properly store food on 2 out of 2 times. This poses a potential health and saftery risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licensee agrees to conduct an inservice on proper food storage by the 5 pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Jan 4, 2022

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: 2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Based on interview the licensee did not ensure that resident was checked at least 1 out of 1 time., this poses a potential health, and saftery risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licensee agrees to have staff document in resident logs that checks and incontinent care has been completed. The POC is due by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569(c)2 · Plan of correction due date: Jan 4, 2022

Health and Safety Code section (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. Based on interviews the licensee did not assist resident when requested. This poses a potential health, safety or person rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: The Licensee agrees to conduct an inservice on care and service, as well as review job descritption. Proof is to be submitted by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(4) · Plan of correction due date: Jan 4, 2022

87464 Basic Services (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement is not met as evidenced by: Based on interview the licensee did not assistance 2 out of 2 residents with their hygiene needs, this poses a potential health safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licensee agrees to create a shower log. Proof of correction is to be be submitted to the department by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: Jan 4, 2022

87555 General Food Service Requirements: (b) The following food service requirements shall apply:(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: based on observation and interview the licensee did not ensure adequate food supplies on hand at minimum 2 out of 2 times. This poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licensee agrees to submit receipts according to facility menu posted to ensure the residents are served complete meals. Proof of correction is to be submitted by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jan 4, 2022

87555 General Food Service Requirements: (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on observation and interview the licensee did not ensure meals of quality and quantity are being served on 1 out of 1 time. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licensee agrees to conduct an inservice on blood borne pathogens Proof of correction is to be submitted by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Jan 4, 2022

87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requrement is not met by Licensee having 5 containers full of medication the need to be destoryed. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licensee agrees to dispose of medication. Medication destruction record will be submitted to the dept by 5pm on the due date indicated.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Javina George arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20211214124454. At the time of LPA visit a series of several beeps or chirping, were heard throughout LPAs visit. The beeping or chirping was coming from multiple smoke detectors throughout the facility located inside of resident and staff bedrooms, hallway and common areas. Due to the non-operable smoke detectors a deficiency is being cited, and immediate civil penalties of $500 are being assessed according to the California Code of Regulations. An exit interview was conducted and a copy of this report, appeal rights LIC421IM was provided to Caregiver Traci Brown.the state’s words, verbatim · CDSS document, Dec 20, 2021

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1548(c)(2)(A) · Plan of correction due date: Dec 21, 2021

Civil penalties;..:(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation...citation for any of the following serious violations:2) (A) Fire clearance violations, including, but not limited to...inoperable smoke alarms, and inoperable fire alarm systems. This requirement was not met as evidenced by: Based on observation, the Licensee did not comply with the above regulation in at least 3. LPA George obeserved non-operational smoke detectors in various locations: Bedrooms, hallways and common area. This is an immediate safety risk to residents.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licensee agrees to replace all smoke detectors in facility by 5pm on the due date indicated.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Licensee Gertrude Okoro and explained 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 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). Staff were also observed wearing appropriate face coverings (N95 mask). The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks two times a day. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility has a covid-19 binder that staff, residents and visitors can refer to ask questions arise. Based on the observations made 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 a copy of this report was provided to Licensee Gertrude Okoro.the state’s words, verbatim · CDSS document, Oct 7, 2021