Pacific Vista Senior Living

Allegation investigated: Staff failed to administer residents' medication as prescribed

Licensing Program Analyst (LPA) Javina George made an unannounced visit to deliver findings for the allegations noted above. LPA met with Jamie Teng, Administrator and explained the purpose of the visit and the elements of the allegation noted above. The allegation was investigated, and the investigation consisted of observations, interviews and records review. Regarding the allegation of staff failed to administer resident’ medication as prescribed. Resident #1 (R1) was admitted to the facility on or around August 3, 2023. Per interviews with Administrator Jamie Teng, there is a contract or agreement with a local skilled nursing facility (SNF) to discharge residents from the SNF to the facility. However, the facility accepted residents without the residents being properly screened, as the evaluation for suitability for admission. Jamie stated that there was no admissions agreement completed, as R1 was only at the facility for a few hours when they began exhibiting aggressive behaviors, as they began to destroy their room. However, another interview conducted with facility staff revealed that R1 was at home for two (2) days and would yell at nighttime. Unsubstantiated Per an interview with SNF staff revealed that R1 was discharged, with a prescription, that was sent to a local pharmacy. In addition, per SNF staff when medication is sent to the pharmacy, the medication will be delivered the same day if not the next day. Per an interview with the local pharmacy staff revealed that R1 did have a profile with them but no medication. LPA inquired as to why there would be a profile, but no medications. The pharmacy staff explained that “it could mean the medications were cancelled, transferred, or were never sent to the pharmacy”. During the initial complaint visit conducted on 8/8/23, LPA did not observe a facility file nor documents, to confirm which medications R1 was prescribed. However, it was confirmed that R1 was discharged from the SNF to the facility and the medication was sent over to the pharmacy. There was no other explanation provided from the Administrator Jamie, other than “no R1 was not given any medication at the facility as they were not a resident. A list of medications was not provided for LPA to review from the Pharmacy, due insufficient evidence the allegation of staff failed to administer residents medication as prescribed is 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(s) occurred. An exit interview was conducted and copy of this report, and appeal rights were reviewed and provided to Jamie Teng, Administrator.the state’s words, verbatim · CDSS document, Oct 5, 2023 · control 18-AS-20230803114230

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit as LPA was delivering findings for complaint control # 18-AS-20230803114230 and observed the following deficiency. The facility admitted (accepted responsibility) for Resident #1 (R1) on or around August 3, 2023. Per interviews with Administrator Jamie Teng, there is a contract or agreement with a local skilled nursing facility (SNF) to discharge residents from the SNF to the facility. However, the facility is accepting residents without properly screening them, as well as not completing the evaluation of suitability for admission. The evaluation consists of: (1) Conduct an interview with the applicant and his responsible person. (2) Perform a pre-admission appraisal. (3) Obtain and evaluate a recent medical assessment). As a result of the facility not properly screening new residents. R1 was admitted to the facility and began exhibiting aggressive behaviors such as banging their head against the wall, and trying to throw furniture. As a result the facility had to contact 9-11 to assist, and have R1 removed without returning to the facility. This poses a potential health, safety and personal rights risk to persons in care. The following is being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report, and appeal rights were reviewed and provided to Administrator Jamie Teng.the state’s words, verbatim · CDSS document, Oct 5, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87456(a)(1-3) · Plan of correction due date: Oct 20, 2023

87456 Evaluation of Suitability for Admission (a)(1-3) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (1) Conduct an interview with the applicant and his responsible person. (2) Perform a pre- admission appraisal. (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by: The licensee failed to conduct an evaluation for R1, 1 time. This posed a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: The licensee agrees to submit a personal statement self certifying that any new residents moving forward the facility will conduct an evaulation of suitability.

Type of visit: Office

Licensing Program Analyst (LPA) Janira Arreola and Licensing Program Manager (LPM) Joel Esquivel conducted an informal office meeting with the administrator and licensee Jaime Teng, Corporate Board Member of RIVERSIDE ELITE ADVANTAGE CARE HOME LLC. The following items were discussed: The administrator failed to provide plan of correction for deficiency cited on 8/4/2023 for Eviction Procedures. The licensee was provided with a copy of eviction procedures in California Code of Regulations under Title 22. During this meeting, the licensee stated they would be informed on eviction procedures to ensure that residents receive a proper eviction when it is required. Licensee unprofessional behavior during 8/4/2023 visit. The licensee agreed during today's meeting to act in a professional manner with CCL staff. In regards to staff competency the licensee agreed to provide training to improve staff competency. They agreed they would be at the facility 20 hours a week at the facility Monday to Sunday from 8am to 12pm and agreed to amend the staff roster to reflect this. In regards to prior complaint allegations, Licensee agreed to provide more training to staff and be more receptive to facility residents to prevent future complaints. In regards to facility Intake process the licensee agreed to have all required paperwork at the facility prior to accepting a new resident. Reporting requirements. The licensee was provided with the public inbox for reporting incidents at the facility in a timely manner: CCLASCPRO@dss.ca.gov In regards to facility records, the licensee agreed to have the records available at the facility and ready for LPA's inspection. In regards to unassociated staff, the licensee agreed to check the facility roster and make sure all staff are associated prior to working at the facility. An exit interview was conduced where this report was reviewed and provided to the Licensee, Jaime Teng.the state’s words, verbatim · CDSS document, Aug 15, 2023

Allegation investigated: Staff cannot communicate with residents in home.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Licensee, Jaime Teng who was informed of the purpose of the visit. During the investigation, LPA conducted interviews, documented observations, and conducted records reviews. It was alleged that staff could not communicate with residents in the home and complete services for them due to limited english. LPA interviewed Four (4) facility residents. Three (3) of the resident interviewed reported being able to communicate with staff. These residents reported no issues with staff communication and services provided. Unsubstantiated One (1) resident was interviewed where it was found that they were unsatisfied with communication with staff, stating they had to repeat themselves serval times, provide clarification, and "yell" at staff when they reported not being able to hear the resident. The resident reported their services where completed. LPA interviewed the (3) staff identified in the complaint. All staff were able to be interviewed in English with LPA. All staff reported being able to communicate with the resident in English. Furthermore, LPA observed S1 and S2 communicating with a resident responsible about the care provided to the resident. LPA was provided with progress notes written b y S1, which were observed to be in English. Therefore, based on observations and interviews, the allegation is unsubstantiated. A finding of unsubstantiated means that the preponderance of the evidence standard has not been met. An exit interview was conducted with Licensee, Jaime Teng where this report was reviewed and provided to them.the state’s words, verbatim · CDSS document, Jun 22, 2023 · control 18-AS-20220916114017

Allegation investigated: Staff failed to provide food Staff failed to provide toileting assistance Staff failed to clean the resident's room Staff failed to administer medications to resident Staff are retaliating against the resident Staff are abusing resident with threats and calling resident bad names

Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit to the facility in order to deliver investigation findings on the above allegations. LPA met with Licensee, Jaime Teng who was informed of the purpose of the visit. During the investigation, interviews were conducted and records were reviewed. It was alleged that on June 10, 2022, staff did not assist Resident 1 (R1) in getting food. Interviews revealed R1 last had staff communicate with them at 9pm on June 9, 2022. R1 made attempts to communicate with staff in obtaining food but staff failed to respond. Attempts were made starting at 8am on June 10, 2022. Interviews revealed that R1 made attempts to several phone numbers including the facility’s landline. R1’s responsible party arrived at approximately 1pm to assist R1 since they had still not been provided food. Interviews were conducted with staff identified as being on duty on June 10, 2022. Staff interviews revealed S2 acknowledged they did not provide any assistance to R1 during their shift. S1 refused to answer interview questions. Licensee interview revealed that licensee was unable to assist due to illness and fraturced communication with the resident. Therefore, based on interviews conducted and records reviewed, the allegation is substantiated. ***CONTINUED ON LIC9099-C PAGES*** Substantiated It was alleged that on June 10, 2022, staff did not provide R1 with toileting assistance. Interviews revealed R1 last had staff communicate with them at 9pm on June 9, 2022. R1 made attempts to communicate with staff in obtaining assistance with toileting but staff failed to respond. Attempts were made starting at 8am on June 10, 2022. R1’s responsible party arrived at approximately 1pm to assist R1 with toileting. Interviews were conducted with staff identified as being on duty on June 10, 2022. Staff interviews revealed S2 acknowledged they did not provide any assistance to R1 during their shift. S1 refused to answer interview questions. Therefore, based on interviews conducted and records reviewed, the allegation is substantiated. It was alleged that R1 had a tray of dirty dishes and the trash was full. These items had been a concern since June 9, 2022 at approximately 9pm. Interviews revealed the staff had not answered phone calls for service nor their messages. R1 attempted to contact staff starting at 8am on June 10, 2022. Interviews were conducted with staff identified as being on duty on June 10, 2022. Staff interviews revealed S2 acknowledged they did not provide any assistance to R1 during their shift. S1 refused to answer interview questions. Therefore, based on interviews conducted, the allegation is substantiated. It was alleged that on June 10, 2022 there were two medications not administered to R1. Interviews revealed that there are two medications stored in a refrigerator in the garage of the facility. LPA observed the two medications stored. Interviews revealed the staff had not answered phone calls for service nor their messages. R1 attempted to contact staff starting at 8am on June 10, 2022. Interviews were conducted with staff identified as being on duty on June 10, 2022. Staff interviews revealed S2 acknowledged they did not provide any assistance to R1 during their shift. S1 refused to answer interview questions. Therefore, based on interviews conducted, the allegation is substantiated. It was alleged that staff are retaliating against R1. Interviews revealed R1 has made complaints and then staff threatened to evict the resident , close the facility and refuse to provide R1 services in retaliation for the complaints. Text messages were reviewed which revealed that licensee had stated the facility would close due to R1 complaining to licensing. Interviews revealed that staff refused to work with the resident and refused to provide services to the resident. Therefore, based on interviews conducted and records reviewed, the allegation is substantiated. ***CONTINUED ON LIC9099-C PAGE*** It was alleged the licensee called R1 “evil.” Interviews revealed the name calling was done via text message. LPA conducted interviews and conducted records reviews. Text messages were reviewed which revealed a text message sent to R1 which read “I am so busy to create goodness not others who only spread evil.” The text message revealed it was sent from contact in phone "Jaime Teng". Interviews with the licensee revealed, the licensee admitted sending the text and he was speaking in generalities, and that the word “evil was not meant toward one person.” The licensee denied ever calling R1 evil. However, text message screenshots sent to the LPA by the licensee, revealed a text message exchange between the licensee and R1. The screenshot further revealed, R1’s contact information was saved using R1’s name followed by the word “evil”. Licensee stated that this word "evil" was a typo "evic" as in evicition. Therefore, based on interviews conducted and records reviewed, the allegation is substantiated. During an interview conducted with the licensee it was revealed, the licensee was unable to be at the facility to assist R1 on June 10, 2022. The licensee stated that S1 and S2 were at the facility to provide care and supervision to the other residents that day. The licensee further revealed that S2 was assisting other residents during the time R1 was requesting assistance on June 10, 2022. The licensee also revealed that S1 did not want to assist the resident. Based on interviews, review of records, and observations, a preponderance of evidence exists to support the allegations. The allegations are therefore substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Licensee, Jaime Teng to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights were provided.the state’s words, verbatim · CDSS document, Oct 6, 2022 · control 18-AS-20220623154318

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(1) · Plan of correction due date: Oct 7, 2022

87555 General Food Service Requirements (b) The following food service requirements shall apply: (1) Where all food is provided by the facility arrangements shall be made so that each resident has…daily food needs are met. Not more than fifteen (15) hours shall elapse between the third and first meal.” This requirement was not met as evidenced by: Based on interviews and records reviewed: facility staff did not provide food to a resident from 9pm on 6/9/2022 to 1pm on 06/10/22. This posed an immediate health and safety, or personal rights risk to R1.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Licensee shall provide training to staff on providing food to residents in care. Training material must include: Ways to ensure residents receive dinner and breakfast in n more than a 15 hour period. Training material and staff sign in sheet shall be sent to LPA by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a)(3) · Plan of correction due date: Oct 7, 2022

87307 Personal Accommodations and Services (a) Living accommodations... The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. This requirment was not met as evidenced by: Based on interviews and record review, the facility staff did not provide a clean commode and toilet paper/wipes on 06/10/22 to R1. This posed an immediate personal rights or health or safety risk to R1.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Licensee shall conduct a training with staff on providing residents with hygiene supplies, and ensuring all residents have access to equipment that allows for proper hygiene. Training materials and staff sign in sheet shall be submitted to LPA by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 7, 2022

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirment was not met as evidenced by: Based on interviews and record review, facility staff did not assist R1 with two medications on 06/10/22. This poses an immediate health, saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Licensee will conduct a training with staff on assisting on medication administration. The licensee shall submit the training material used and the sign in sheet with staff attending training to LPA by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 7, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews and records review, the licensee saved R1’s name as “evil” in their phone, & sent R1 text messages about being evil. This posed an immediate personal rights risk to R1.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Licensee shall conduct a training with staff on resident personal rights. Training material must include: affording residents diginity in personal relationships with staff. Training materials and sign in sheet of staff attending traioning shall be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Oct 7, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature. This requirement was not met as evidenced by: Based on interviews and record review, facility staff refused to provide basic services to R1. Text messages also revealed R1 was sent texts threatening eviction and facility closure.This posed an immediate personal rights, health or saftey risk to R1.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Licensee will conduct a training with staff on resident personal rights which must include; actions that would be punitive against a resident. Training materials and staff sign-in sheet shall be sent to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 17, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews and record review, facility staff did not clear out dirty dishes and full trash bin after assistance was requested on 06/10/22. This posed a potential health, safety or personal rights risk to R1.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Licensee shall conduct a training with staff on keeping resident accomidations clean, safe, and healful. Training material and staff sign in sheet shall be sent to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit to the facility for a case management visit. LPA met with Licensee, Jamie Teng, who was informed of the purpose of the visit. The LPA had requested a written record of care for Resident 1 (R1) on October 4, 2022. The licensee informed the LPA on October 4, 2022 they did not have a written record of care for R1. During today’s visit, the LPA reviewed R1’s resident file and found it did not contain a written record of care. A deficiency was cited. The review of R1’s file also revealed the admission agreement is not signed by R1. R1 was admitted to the facility on May 10, 2022. A completed admission agreement is required within 7 days. A deficiency was cited. An exit interview was conducted where a copy of this report along with LIC809-D page, and appeal rights were reviewed and provided to Licensee, Jamie Tengthe state’s words, verbatim · CDSS document, Oct 6, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Nov 4, 2022

87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. This requirement was not met as evidenced by: Based on interview and records review it was found that the licensee did not ensure the admission agreement signed within the required time frame. This poses a potential health, safety, or personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Licensee will speak with the residents responsible party to have the agreement signed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87467(a) · Plan of correction due date: Nov 4, 2022

87467 Resident Participation in Decisionmaking (a)... within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative... and any other appropriate parties, to prepare a written record of the care the resident... regarding the services provided at the facility. This requirement was not met as evidenced by: Based on interview and records review it was found that the licensee did not ensure a written record of care was completed. This poses a potential health, safety, or personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Licensee will document efforts to contact physican and home health nurse to get a services plan for the resident.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to issues deficiencies observed. LPA met with staff Evangelica Dela Rosa who was informed of the purpose of the visit on 10/4/2022. LPA found through interview with Licensee that Staff #1 (S1) was a candidate for hire at the facility. Licensee stated that (S1) had not been fingerprinted and had not been at the facility. LPA interviewed a staff member who stated that S1 had been working at the facility in a resident’s room. LPA interviewed resident mentioned by staff, who stated S1 had been working and assisting her at the facility for the week of 09/11/2022 to 09/17/2022. LPA reviewed the Guardian roster for the facility and found that S1 was not listed, Licensee confirmed that he had not yet associated, hired, or fingerprinted this staff member. Therefore, based on staff and resident interviews, and review of staffing records it was found that a civil penalty will be issued for uncleared staff member who had resident contact. LPA will issue a civil penalty for $100 per day per person to the maximum of 5 days, resulting in $500 civil penalty. This will be documented on LIC421BG form along with LIC809-D and plan of correction. An exit interview was conducted where this report, LIC809-D, appeal rights, and LIC421BG were review with…Reports were provided to Evangelica Dela Rosathe state’s words, verbatim · CDSS document, Oct 4, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 5, 2022

"87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department ..." This requirment was not met as evidenced by: Staff and resident interview confiming employee is working at the facility and is not fingerprinted. This is an immediate personal rights, health or safety risk.the state’s words, verbatim · CDSS document, Oct 4, 2022

Plan of correction: Licensee will inform staff they are not to return to the facility until they are fingerprint cleared.Licensee will get staff cleared before working or having contact with residents going forward.

Type of visit: Case Management - Health Checks

Licensing Program Manager (LPM) Deborah Mullen conducted an unannounced visit for the purpose of a health and safety inspection. LPM met with Jamie Teng, Licensee and was granted entrance into the facility. LPM interviewed Licensee, Resident 1 (R1) and Staff 1 (S1). LPM did not observe any immediate health and safety concerns at the time of the visits. LPM discussed with Mr. Teng the requirement to assist resident and provide meals as well as provide assistance with emptying residents commode. mr. Teng confirmed that he will ensure resident is provided meals and that the commode is emptied for the resident. LPM conducted an exit interview with Mr. Teng. This report was reviewed with Mr. Teng and a copy of report was provided to him. Note: A hand-typed version of this report was provided to licensee. The original signature acknowledging receipt of report is on file.the state’s words, verbatim · CDSS document, Jun 10, 2022

Allegation investigated: Facility is issuing an unlawful eviction notice to resident.

Licensing Program Analyst (LPA) Janira Arreola arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation. LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Jaime Teng. Below is a summary of the complaint investigation findings: Regarding allegation of an unlawful eviction notice: LPA Arreola interviewed staff and resident regarding the allegation. LPA reviewed proof of the eviction notice that was issues to the resident, and the admissions agreement that was signed by Administrator Jaime Teng. LPA reviewed these documents along with text messages and e-mail conversations. The evicition notice does not cite any reason included in Title 22 Section 87224(a)(1) through (5). Substantiated Therefore, based on interviews and file review conducted, the allegation of "Facility is issuing an unlawful eviction notice to resident" 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 Arreola, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Administrator, Jaime Teng.the state’s words, verbatim · CDSS document, Jun 3, 2022 · control 18-AS-20220527135858

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Jun 13, 2022

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) LPA reviewed 30-day eviction given to resident and observed that the eviction did not cite a reasoing detailed in Title 22.the state’s words, verbatim · CDSS document, Jun 3, 2022

Plan of correction: Licensee will acknowledge that this eviction notice is invalid and unlawful. Licensee shall not imporerly evict any other resident at their facility.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Janira Arreola went to the facility for an unannounced visit pertaining to a complaint investigation 18-AS-20220527135858. During the investigation LPA and Administrator Jaime teng, observed the following deficiencies: Upon doing record review, LPA found that Eviction notice that had been issued by the facility had not been reported to the department. This goes against Title 22 regulation on Eviction Procedures. Facility will receive a type B deficiency for this, and will be documented on an LIC809-D. Upon reviewing the facility roster LPA found that S1 was not associated to the facility and did not posess a background clearance. This is a violation of the zero tolerance regulation found in Title 22. Facility will receive a Type A citation for this as well as a civil penalty of $500. This will be documented on a LIC809-D. An exit interview was conducted and a copy of this report, appeal rights, and 809-D pages were reviewed and provided to facility Administrator, Jaime Teng.the state’s words, verbatim · CDSS document, Jun 3, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224 · Plan of correction due date: Jun 13, 2022

87224 Eviction Procedures(f) A written report of any eviction shall be sent to the licensing agency within five (5) days. Based on record review and interview, Licensee did not submit the 30-day evicit to the department.the state’s words, verbatim · CDSS document, Jun 3, 2022

Plan of correction: Licensee will submit all eviciton notices to the department with in the (5) day time constraints.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80019(e)(1) · Plan of correction due date: Jun 3, 2022

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: 80019 Criminal Record Clearance (1) Obtain a California clearance or a criminal record exemption as required by the Department LPA conducted record review and found that S1 was not associated and did not possess a background clerance.the state’s words, verbatim · CDSS document, Jun 3, 2022

Plan of correction: LPA will issue civil penalties, and S1 is to not return to work without a proper background clearance.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 9:30 AM, signed in and utilized hand sanitizer. The LPA met with Administrator, Jamie Teng, and informed him of the purpose of her visit. There are currently no cases of COVID-19 within the facility. During today's visit, the LPA toured the facility and made observations pertaining to the facility's infection control measures. The LPA observed sufficient cleaning and disinfecting provisions and proper use of face coverings. 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 the proper use and disposal of PPE and overall infection control. The facility has a plan (Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report) in place which follows Community Care Licensing guidelines for when and how long to test staff and clients for COVID-19, when and how to isolate/quarantine clients, 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 clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. During today's visit the LPA observed the following violations: medication closet not locked and medication stored in kitchen pantry which was also unlocked. This poses a potential health and safety risk to the residents in care. A citation will be issued. An exit interview to review this report was conducted with Teng and a copy was provided, along with the Appeal Rights.the state’s words, verbatim · CDSS document, Mar 29, 2022

Allegation investigated: Facility failed to observe resident's change in condition. Facility did not obtain timely medical treatment for resident.

Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to deliver findings for the allegation(s) listed above. LPA met with Caregiver Luisa Agnote and explained the purpose of the visit as well as the elements of the allegations. Administrator Jamie Teng was unavailable The allegation was investigated by the department. The investigation consisted of observation and interviews. Allegation: Facility failed to observe resident's change in condition. Resident #1 (R1) was receiving hospice services began on October 1, 2019. It was noted in the case notes on March 6, 2020 that there was a change with R1’s big toe. The notes revealed that the toe was red and swollen, tender to touch, began to change colors; purple then black in some areas, prompting for a referral being made to the Podiatrist. R1 was seen on March 30, 2020, by the podiatrist where R1 was diagnosed with vascular (circulation) insufficiency, and not gangrene, surgery was recommended. However, per R1s POA, whom confirmed that they were informed of the change in R1s condition, also stated that R1 declined to have the surgery after being educated on the risks associated without having the surgery, as well as the benefits of having the surgery. Members of R1s treatment team did have knowledge of the change in condition and followed the recommendation from the hospice nurse to see the podiatrist. Unfounded Additionally, a subsequent referral was made for R1 to see the Podiatrist, however per the Podiatrist letter dated May 20, 2020, without the surgery there was not too much that could be done. Therefore, the department has found that the complaint of Facility failed to observe resident's change in condition was UNFOUNDED. Allegation: Facility did not obtain timely medical treatment for resident. LPA conducted interviews and reviewed statements from R1’s POA. Resident #1 (R1) was receiving hospice services, 5 times a week. It was noted in R1 case plan the plan to seek medical treatment and to contact with hospice first in matters relating to medical emergencies. LPA conducted interviews, per the Podiatrist whom saw R1 on 3/30/20, the recommendations were if R1 was in pain to keep legs down to increase circulation in the lower extremity, massage and increase walking. Per a written statement dated 5/20/20 from the Podiatrist, there was an additional request for an appointment, however podiatrist stated” that there is not much else that could be done from a podiatrist standpoint and that resident should be seen by a vascular specialist due to the current circulation issues”. R1 declined moving further with any other treatments and passed away on 7/30/20. The cause of death was Cardiorespiratory arrest. The allegation of Facility did not obtain timely medical treatment for resident is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Therefore the department has dismissed the complaint.the state’s words, verbatim · CDSS document, Aug 16, 2021 · control 18-AS-20200602114358