Atria Rancho Mirage

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one-hundred twenty-five (125) residents live at this facility. There are twenty-six (26) staff members present. The Administrator, Monique Moreira conducted the tour. The Business Director, Sandra Zendejas completed the tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Five (5) record were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. (Continued on LIC809C) (Continuation from LIC809) Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 78 degrees for the resident’s comfort. Lighting is sufficient for safety. Water temperature measured at 108.0 degrees F. Laundry is done in the designated laundry room on the first floor. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is not a fireplace at this facility. There is a gated pool at the facility, that is surrounded by a 5-foot gate and latch. The facility had their last annual fire inspection by Fire Master on 11/16/2022. LPA reviewed the facility’s last disaster drills, which met the department's requirements. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. (Continued on LIC809C) (Continuation from LIC809) Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked pushcart allocated for medication storage in the Medication Room. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed if they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The fire extinguishers throughout the facility were last serviced and tagged on 11/22/22. According to the fire inspection, there are nineteen (19) fire extinguishers throughout the facility. Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Business Manager, Sandra Zendejas.the state’s words, verbatim · CDSS document, Sep 25, 2023

Allegation investigated: Facility staff is financially abusing resident.

Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with Executive Director Monique Moreira and explained the purpose of the visit. Department staff investigated this allegation. The allegation alleged that the reporting party (RP) shares a bank account with resident # 1 (R1) and noticed that R1 was writing checks to unknown individuals. Department staff interview with the RP revealed that they have access to R1’s bank account and noticed that two checks were written to two (2) individuals. The RP stated that they do not know either of these people. The RP stated that they questioned whether or not the signature on the checks was R1’s signature. The RP stated that both checks were cashed. The RP stated that R1 accuses people of stealing from them. Department staff interview with the Executive Director (ED) revealed that on March 12, 2021, the RP brought two (2) check images to the ED that were cashed from R1’s bank account. ED stated that on February 9, 2021, Substantiated , a check was written to one (1) individual for $100.00. The ED stated that R1 rarely leaves their apartment and cannot leave the building unassisted. The ED stated that due to finding this check, the RP began to look for other questionable checks that cleared R1's bank account. The ED stated that the RP discovered that on November 11, 2020, another check was written for $150.00 to staff # 1 (S1). ED stated that on March 1, 2021, at 2:00 p.m., they and a manager at the facility spoke with S1 regarding the cashed check for $150.00. The ED stated that S1 confirmed receiving a $150.00 check from R1. The ED stated that S1 stated the $150.00 was a repayment for purchasing items at R1’s request, using S1's own money. The ED stated that they asked S1 if they were aware of the facility’s policy about not accepting money from residents, and S1 confirmed that they were aware of the policy. The ED asked S1 if they knew the name of the individual who received the other check for $100.00. The ED stated that S1 stated they knew someone with the same first name; however, the last name of the individual they know is different. The ED stated that the other check for $100.00 was written to S1’s boyfriend. The ED confirmed that S1’s boyfriend did not live in the facility or work at the facility. The ED stated that S1 denied that they asked for any money at any time. The ED and manager went to speak to R1. ED stated that R1 denied knowingly giving anyone in the community a check. The ED stated that R1 denied asking anyone in the community to purchase items for R1 at the store. The ED stated that for violating the facility’s policy, S1 is no longer an employee. Based on the evidence gathered during the investigation, the above allegation 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. An exit interview was conducted where a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provided. Allegation #2 “Facility staff do not treat resident with dignity”. The allegation alleged that a facility staff member was very rude to R1. Department staff interview with the ED revealed that the ED denied this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. 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 copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2023 · control 18-AS-20210302135250

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 30, 2023

87468.1 Personal Rights of Residents in All Facilities (a)(3) (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money ... This requirement was not met, as evidenced by the following: Based on interviews, the facility did not ensure that R1’s checkbook was safeguarded from S1, which posed a potential health, safety, and personal rights violation to persons in care.the state’s words, verbatim · CDSS document, May 22, 2023

Plan of correction: The facility shall submit proof of reimbursement to R1 for the stolen monies to the regional office (RO). The POC due date is 05/30/2023.

Allegation investigated: Lack of supervision resulted in resident sustaining injuries from falls. Facility failed to provide resident with planned activities. Staff did not ensure that resident's care needs were met while in care.

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Executive Director (ED), Monique Moreira, and informed her of the purpose of her visit. The investigation included staff/resident interviews, records review and records collection. An allegation was reported to the Department alleging lack of supervision of Resident One (R1) who sustained injuries as a result of several falls. The resident's Physician's Report for Residential Care Facilities for the Elderly (RCFE) was reviewed; it revealed R1 has no motor impairment/paralysis and has a designated nonambulatory status. The Resident Functional Needs Service Plan revealed R1 requires intervention three times per day to decrease identified fall risk. Staff interviews revealed R1 did sustain two falls while in care. According to interviews and a Resident Note, no injuries were observed on R1 when assessed after two falls occurred on April 04, 2023. R1 declined to be interviewed. Therefore, due to insufficient information, this Unsubstantiated allegation is deemed UNSUBSTANTIATED at this time. It was also alleged facility staff failed to provide R1 with planned activities. Staff interviews revealed R1 was encouraged to come out of their bedroom to participate in activities; however, the resident refused to leave their room. An interview was attempted with R1, however, they declined to answer any questions. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. Lastly, it was alleged facility staff did not ensure R1's care needs were met while in care. It was reported R1 was left in the same clothing worn the day prior, and not assisted to change. Staff interviews revealed R1 was assisted to change partially, however, declined further assistance from staff on or around April 04, 2023. R1 declined to be interviewed. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. 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 violations occurred. This report was reviewed with Moreira and a copy was provided.the state’s words, verbatim · CDSS document, May 9, 2023 · control 18-AS-20230505131306

Type of visit: Case Management - Other

On March 17, 2023, Licensing Program Analysts (LPAs) Chinwe Nwogene and Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit regarding an eviction process taking place. During the visit, staff and resident were interviewed, resident file and facility record was reviewed to make sure the eviction process is in compliance with Title 22, California Code of Regulations. No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Monique Moreira.the state’s words, verbatim · CDSS document, Mar 17, 2023

Type of visit: Office

An office meeting was held on this date with Deborah Mullen, Licensing Program Manager, Jesse Gardner, Licensing Program Analyst, and Nicole Wentworth, Regional Vice President. The meeting was to discuss the current management team in place at Gladwell Rancho Mirage. During the meeting it was confirmed that the managing members identified on the Administrative Organization form submitted June 26, 2019 are still current. Wentworth was asked to submit a current Personnel Report (LIC500) to the office by January 27, 2023. Wentworth was given LPA Stephanie Torres' contact information who is the current assigned LPA. An exit interview was conducted and a copy of this report was reviewed with and provided to Nicole Wentworth.the state’s words, verbatim · CDSS document, Jan 23, 2023

Allegation investigated: Staff do not respond to residents pull cords in a timely manor Facility does not have adequate staffing to meet the needs of the residents. Facility is not providing food of the quality and quantity to meet the resident's needs. Staff are not properly trained

Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegations. LPA met with Sandra Zendejas and explained the purpose of the visit. At approximately 11:00 a.m. the interim Executive Director April Princesa arrived at the facility. The investigation consisted of file reviews and interviews with relevant parties. Allegation #1 “Staff do not respond to residents pull cords in a timely manner”. The allegation alleges that the facility does not answer the resident's pull cords timely. The allegation further states that it takes the facility staff an hour to respond. LPA file review of the pull cord log revealed that in July 2020, staff responded to the client’s pendants within 15 minutes or less. LPA interviews with staff revealed that facility staff responds to client pendants within 15 minutes or less. Investigation into this incident reveals insufficient evidence to corroborate the allegation. Unsubstantiated Allegation #2 “Facility does not have adequate staffing to meet the needs of the residents”. LPA interviews with facility staff revealed that the facility has enough staff to meet the client's needs. LPA interviews with clients revealed that the clients could not remember if there was enough staff working at the facility in July 2020. Investigation into this incident reveals insufficient evidence to corroborate the allegation. Allegation #3 “Facility is not providing food of the quality and quantity to meet the resident's needs”. The allegation alleges that the food is not of good quality. The allegation further alleges that the bread is stale, the eggs are powdered, and the food is terrible. LPA interviews with staff revealed that the clients are provided food of good quality and quantity. LPA interviews with clients revealed that the clients could not remember the quality and quantity of food in July 2020. LPA file reviews revealed that the facility contracts with Crandall Dietitian Services which creates the facility’s food menus. Investigation into this incident reveals insufficient evidence to corroborate the allegation. Allegation #4 “Staff are not properly trained”. The allegation alleges that the facility’s staff are not properly trained to do transfers. LPA file reviews of staff training records revealed that facility’s staff were properly trained. Based on the investigation, the above findings are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.the state’s words, verbatim · CDSS document, Jan 17, 2023 · control 18-AS-20200706114152

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to conduct a case management visit to follow up on information that the Department needed. LPA met with Business Director Sandra Zendejas and toured the facility. LPA advised Zendejas that an updated LIC500 is needed by CCL and to provide to LPA by January 17, 2023. Upon review of the facility roster found in Guardian, LPA noted that Assistant Executive Director (Interim Administrator) April Princesa was not associated to Gladwell Rancho Mirage. Princesa began employment in mid November, 2022, and is at the facility on Tuesday, and Wednesday's, and some weeks it rotates to Wednesday, Thursday's. Princesa was not on property at the time of visit. Deficiency was cited per Title 22. No other citations were noted on today's visit. An exit interview was conducted where a copy of this report was discussed and provided along with the LIC809-D, LIC421-BG, and Appeal Rights.the state’s words, verbatim · CDSS document, Jan 12, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(g)(2) · Plan of correction due date: Jan 13, 2023

Personnel Requirements: (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This was not being met as evidenced by: Based on LPA's record review of the clearance roster, S1 was not found to be associated to Gladwell Rancho Mirage. This poses a potential health and safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Licensee agrees to transfer Princesa to Gladwell Rancho Mirage and submit proof of such to LPA by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Community Business Director Sandra Zendeias, and Administrator Monique Moreira (via telephone) and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. LPA Colvin did not conduct a tour of the community, as the facility has an active COVID-19 outbreak at this time. Below is a summary of inspection: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Community Business Director Sandra Zendeias, and reviewed the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels, and hand washing guides are posted. Upon entering the facility, LPA Colvin observed postings for cough etiquette, social distancing, and infection control. Community Business Director Sandra Zendeias and Administrator confirmed plenty of PPE supplies (such as masks, gowns, gloves). LPA Colvin went over the various recommended training for facility staff with Community Business Director Sandra Zendeias in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. Community Business Director Sandra Zendeias confirmed that all staff have been fit tested, and that they will be re-fit tested annually. LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Community Business Director Sandra Zendeias confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility, which LPA Colvin confirmed through being screened upon entry as well. LPAs Colvin additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions. Administrator stated New Administrator Packet was previously sent to Licensing. LPA Colvin to follow up. An exit interview was conducted with Community Business Director Sandra Zendeias and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 23, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA Gardner met with Executive Director Jonathan Karp. Present in the facility during time of visit were forty-eight (48) staff as well as eighty-nine (89) clients. There are currently no cases of COVID-19 within the facility. During today's visit, LPA Gardner toured the facility and made observations pertaining to the facility's infection control measures. LPA Gardner observed sufficient hand hygiene supplies, 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. During the inspection LPA Gardner discussed infection control practices and procedures with Mr. Karp. An exit interview was conducted and a copy of this report, was reviewed with and provided to Mr. Karp.the state’s words, verbatim · CDSS document, Sep 29, 2021

Allegation investigated: Facility staff do not speak to residents with dignity. Facility staff failed to provide incontinent care to a resident. The dementia unit patio and living room are dirty.

Licensing Program Analysts (LPAs) Anna Bueno and Amy Goldenberg conducted a subsequent unannounced visit for the purpose of concluding this agency's investigation into the complaint allegations mentioned above. The investigation consisted of file reviews and staff and witness interviews. Allegation 1: Facility staff do not speak to residents with dignity. RP alleges that she overheard staff speaking sternly to a resident. Interviews revealed that this was a possible interaction between paramedic and resident who was hard of hearing. No other information was obtained regarding this allegation. Allegation 2: Facility staff failed to provide incontinent care to a resident. RP alleges that Resident 1 (R1) was left in the same diaper for 26 hrs because they were wearing the same grey diaper when RP arrived the next morning. During interviews, LPAs discovered that R1 was being showered by staff when RP arrived that morning and that grey diapers are supply stock kept by the facility. Allegation 3: The dementia unit patio and living room are dirty. Information disclosed during interviews revelead that maintenance crews clean the ***** CONTINUED ON LIC-9099C ***** Unsubstantiated the patio every morning and housekeeping staff clean the living room every day. LPAs toured the memory care unit which includes the dining and activity room, media room that opens to the patio, and the patio. LPAs observed these rooms to be clean and free of debris. Based on interviews and observations, findings for the above allegations are therefore UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies have been cited at this time. An exit interview was conducted where this report was discussed, and a copy was provided to the Executive Director.the state’s words, verbatim · CDSS document, Jul 30, 2021 · control 18-AS-20210301104814

Allegation investigated: Resident fell while in care.

cThis unannounced visit conducted by Amy Goldenberg and Anna Bueno, Licensing Program Analyst (LPAs), is being conducted to conclude this agency’s investigation into the complaint allegation mentioned above. During the course of the investigation LPA reviewed resident notes for R1 dated 10/03/2020 through 10/22/2020, one incident report dated 10/15/2020, and conducted interviews with three employees. It is alleged that R1 had a fall while in care and sustained scrapes and bruises on his knees. LPA learned the following information: The date of injury is unknown. R1 resided in the memory care unit of the facility from 10/03/2020 through 10/20/2020. Review of resident notes and the incident reported do not reveal that R1 fell while in care. Interviews conducted did not confirm that R1 had an injury or fall while in care at the facility and sustained scrapes and bruises on his knees. Unsubstantiated Based on the aforementioned, there is not enough available evidence to corroborate or refute the allegation. We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and a copy is being furnished to Executive Director Jonathan Karp.the state’s words, verbatim · CDSS document, Jul 30, 2021 · control 18-AS-20210426161704