Attentive Manor II

Allegation investigated: Staff was in a verbal altercation in presence of a resident.

Licensing Program Analyst (LPA) Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegation listed above. LPA met with Licensee, Matt Siegel where LPA explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observation, interviews with staff members and residents, and record review. LPA was unable to obtain contact with additional witnesses. On 08/10/2023, Community Care Licensing received a complaint stating that staff was in a verbal altercation in presence of a resident. It was reported that staff members were arguing and having an inappropriate interaction in front of Resident #1. In regards to the allegation that staff was in a verbal altercation in the presence of a resident, information obtained from interviews stated that there was no verbal altercation incident that occurred in front of residents. Interviews with residents indicated that there were no issues or concerns regarding staff behaving appropriately. Interviews with residents corroborated the information obtained from staff. (Continued on 9099-C) Unsubstantiated Continuation from 9099) Based on LPA’s observation, interview conducted and record review(s), the preponderance of evidence shows that the allegations is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, a copy of this report, appeal rights was provided to the Licensee, Matt Siegel, as evidenced by his signature.the state’s words, verbatim · CDSS document, Oct 16, 2023 · control 18-AS-20230810164347

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Licensee, Matthew Siegel, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and (5) residents present. The facility is a one-story home with six (6) bedrooms and four (4) bathrooms with attached garage. The residents served are elderly adults 65 years of age and older. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following: 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. LPA reviewed staff records and found that all staff had infection control training. Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational, and the hot water temperature 118.2 F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff are present for the supervision of residents during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate. Record Review and Resident/Staff Files: LPA reviewed two (2) staff files and training. All staff updated training along with CPR/First Aid Certification. LPA observed Staff # 1 (S1) did not have criminal record clearance and was working at this facility for approximately one month. A civil penalty will be issued. Three (3) resident files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All resident medication was locked in a closet near the kitchen. LPA reviewed medications for (3) residents and found all medication listed on MARS and all required labeling was found to be in place. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA interviewed Licensee regarding fire and earthquake drill and he stated the facility holds monthly staff training for fire and earthquake drills which met the department requirements. LPA advised to have written documentation available at the facility of the fire and earthquake drills. Technical Assistance will be issued. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items. An exit interview was conducted where a copy of this report, LIC809D, Civil Penalty, and appeal rights was provided to Licensee, Matthew Siegel.the state’s words, verbatim · CDSS document, Jul 14, 2023

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPA was greeted by Caretaker Irma Vazquez and explained the purpose of today's visit and signed into the facility. There were 5 residents inside the facility. Licensee Matthew Siegel was present inside the facility at the time of visit. During today’s visit, LPA toured the facility and made observations pertaining to the facility’s infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, and sufficient cleaning and disinfecting provisions, but noted the facility was deficient in their 30-day supply of Personal Protective Equipment (PPE). Thus, a Technical Advisory was issued. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19. When and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. LPA noted through the infection control tool that Ms. Vazquez doesn't have a fit test for a N95 mask. LPA issued a Technical Advisory in relation to the fit test. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illness. An exit interview was conducted, and a copy of this report was discussed with and provided to Mr. Siegel along with copies of the Technical Advisory's issued.the state’s words, verbatim · CDSS document, Jul 22, 2022

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Yolanda Delgado conducted a case management visit to the facility. LPA met with Certified Nursing Assistant Gabriel Boudet and explain the purpose of the visit. During the visit, LPA spoke to Administrator Matthew Siegel by telephone and confirmed Attentive Manor (336426470) has no residents in placement. Mr. Siegel referred LPA to Administrator Christopher Peck for further assistance to obtain the requested documentation regarding a complaint control # 18-AS-20200529135656 at Attentive Manor (336426470). LPA spoke with Mr. Peck by telephone and arranged to have the requested documents emailed to LPA by the end of the day. An exit interview was conducted, and a copy of this report was reviewed and left with Mr. Boudet. *****This is an Amended Report********the state’s words, verbatim · CDSS document, Oct 28, 2021

Allegation investigated: Staff is verbally abusive towards residents Authorized representative was not provided a refund Staff did not follow physicians orders for medication

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation for a complaint with the above allegation(s). LPA Colvin was granted entrance and met with Administrator Chris Peck, who assisted LPA Colvin during today's inspection. Licensee Matt Seigel additionally arrived for part of the investigation and assisted. Below is a summary of today's findings: Regarding allegation "Staff is verbally abusive towards residents": LPA Colvin interviewed residents, staff, and outside parties regarding the allegation of the complaint. Multiple people interviewed stated that the Licensee, Matt, had on several occasions been verbally abusive to R1. LPA Colvin was also learned that Licensee Matt has been verbally abusive to other resident(s) in the facility. Such reported abuse includes inappropriate statements regarding residents' finances, health, or functional capabilities. Licensee Matt denied allegations. Therefore, based on interviews conducted, the allegation "Staff is verbally abusive towards residents" is SUBSTANTIATED. Substantiated Regarding allegation "Authorized representative was not provided a refund": LPA Colvin reviewed R1's file at the facility as well as interviewed the Licensee and R1's POA. LPA Colvin learned that after R1 left the facility after being there only two months, the Licensee did not provide a refund of the Pre-Admission Fee, which contradicts both Title 22 Regulations and the facility's signed Admissions Agreement. Licensee Matt admitted to not providing R1's POA with any refund except for $100 of "petty cash" left of the $200 given to the facility at the beginning of R1's stay. Therefore, based on record review and interviews, the allegation "Authorized representative was not provided a refund" is SUBSTANTIATED. Regarding allegation "Staff did not follow physicians orders for medication": LPA Colvin conducted interviews with staff and reviewed R1's file at the facility. LPA Colvin was unable to review the Medication Administration Log (MAR) that the facility utilizes, as the facility had not maintained a copy in R1's archived file, and the copy maintained by the pharmacy was not available for LPA Colvin during today's inspection. It is worth noting that the facility does keep a physical MARs log for residents, but afterwards scans the log to the pharmacy. LPA Colvin observed that while a file for R1 was archived at the facility, this record for R1 was not. LPA Colvin was provided with a blank print out with no signatures or notes for administration of R1's medication. LPA Colvin asked Administrator Chris Peck if the facility does any other notation for "as needed" (PRN) medications on the MARs log, and Chris confirmed that it would be written on the back the time of the administration and the effect it had on the resident. These notes were not available to LPA Colvin during today's inspection, so LPA Colvin cannot verify that staff administered the medications correctly. Therefore, based on interviews and lack of records, the allegation "Staff did not follow physicians orders for medication" 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 this report and appeal rights were discussed. A copy of this report, LIC9099Ds, and appeal rights was provided to Administrator Chris Peck during the exit interview. Regarding allegation "Medications were accessible to resident in care": LPA Colvin conducted a tour of the facility and inspected a couple of resident bedrooms and did not observe any medications. LPA Colvin additionally observed the medication closet in the kitchen area to be locked when LPA Colvin arrived. LPA Colvin was not provided with any additional evidence of prior instances of medications being accessible to resident(s). Therefore, based on observations and lack of evidence, the allegation "Medications were accessible to resident in care" is UNSUBSTANTIATED. Regarding allegation "Staff took resident's personal belongings off the wall of bedroom": LPA Colvin conducted interviews with staff and outside parties regarding the allegation. Interviews conducted conflict on what transpired, and no evidence was provided (or available) for LPA Colvin to review in regards to this allegation. Therefore, based on lack of evidence, the allegation "Staff took resident's personal belongings off the wall of bedroom" is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Administrator Chris Peck and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 2, 2021 · control 18-AS-20210824111213

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87507(g)(5)(E)(2)(b) · Plan of correction due date: Sep 6, 2021

Admission Agreements: (g) Admission agreements shall specify...: (5) Refund conditions. (E) Preadmission fees shall be refunded...: 2....shall be refunded...: b. A refund of at least 60 percent...shall be provided if the resident leaves the facility...during the second month of residency. This was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with one resident (R1). R1's POA was not provided with a refund of the amount of the preadmission fee as laid out in this regulation and the Admissions Agreement. This was an immediate personal rights violation.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee agrees to provide R1's POA of the applicable refund amount of the preadmission fee. Licensee to provide LPA Colvin with proof of refund and proof refund was submitted to R1's POA. Proof requested is due by Plan of Correction date of 9/6/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 16, 2021

Incidental Medical and Dental Care: (c).... facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:(3) A record of each dose is maintained in the resident's record... This requirement was not met by: Based on interviews and lack of records, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed there was no record of PRN medication doses administered in R1's file. This was a potential health and safety risk of R1.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee agrees to have applicable staff re-trained on record keeping. Licensee to provide LPA Colvin with proof of training by Plan of Correction date of 9/16/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 6, 2021

Personal Rights of Residents in All Facilities: (a) Residents...shall have all of the following...: (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 conducted, the Licensee did not comply with the above regulation with one staff member (Licensee). Interviews revealed that Licensee has been verablly abusive to more than one resident in care. This was an immediate personal right violation to multiple residents, including R1.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee agrees to have staff retrained on Reporting Requirements. Licensee to provide LPA Colvin with a date for staff training by the Plan of Correction date of 9/3/21, and a proof of staff training once completed.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of investigating a complaint (#18-AS-20210824111213). During LPA Colvin's inspection, LPA Colvin observed additional items that needed to be addressed with the Administrator. Below is a summary of what was observed: Unassoicated Staff - LPA Colvin observed that two staff members (S1 & S2) are working at the facility but are not associated. LPA Colvin was able to confirm background clearance for both staff, but in review of their files at the facility LPA Colvin did not locate a clearance transfer request to the facility, which is required for the staff to be associated. A facility must have submitted a transfer request for staff with background clearance prior to them working in the facility. Deficiency cited. This deficiency comes with a civil penalty in the amount of $100 per day, per staff, for a maximum of 5 days. Since both staff have worked at the facility for longer than 5 days, the maximum penalty of $500 per staff ($1,000 total) will be assessed. Locked Perimeter - LPA Colvin observed that the facility's front and side gate both have an electronic lock which requires a security code to unlock. LPA Colvin reviewed the facility's application and fire clearance and observed that the facility has not been approved for a locked perimeter. LPA Colvin additionally contacted the Cathedral City Fire Department and confirmed that the Fire Marshall did not approve the locked perimeter. Deficiency cited. A violation of a facility's fire clearance comes with an immediate civil penalty in the amount of $500, which will be assessed today. Licensee requested LPA Colvin to submit request to Fire Department for inspection for approval for delayed egress . Resident Funds - LPA Colvin observed that the facility is holding on to resident funds (average of $200 for each resident). LPA Colvin reviewed the facility's application for license and confirmed that it was stated to Licensing that they would not handle resident funds. Deficiency cited. Additionally, LPA Colvin confirmed with the Licensee that the facility does not have a surety bond, which would protect clients' money in the event of a theft. Deficiency cited. Lastly, in review of a resident's file (R1) in relation to a complaint, LPA Colvin observed that there is no accounting ledger for the resident's money. LPA Colvin inquired with the Licensee about this, and the Licensee stated that the funds are kept in an envelope along with receipts for purchases. No other accounting ledger is utilized to itemize expenses to ensure an accurate accounting of the funds held for the resident by the facility. Deficiency cited. Lastly, LPA Colvin learned in an interview with the Licensee and Administrator that R1's funds of $200 was returned to R1's Power of Attorney (POA) with $100 taken out, in order to account for repairs needed on a toilet used by R1. Title 22 Regulations state that a facility cannot use resident's personal funds (such as R1's $200) for expenses or as a deposit. Deficiency cited. Reporting Requirements - LPA Colvin observed that though R1 went to the hospital on numerous occasions for emergency services, and was even admitted for several days on at least one occurance, the facility never submitted an Special Incident Reports (SIRs) to Community Care Licensing (CCL). Facilities are required to report to CCL any event or occurrence which may pose a risk to a resident's health or safety. Deficiency cited. Due to observations made by LPA Colvin, the facility was cited and civil penalties in the amount of $1,500 were issued, An exit interview was conducted where this report and appeal rights were discussed. A copy of this report, LIC809D, LIC421BG, LIC421IM, and appeal rights was provided to Administrator Chris Peck during the exit interview.the state’s words, verbatim · CDSS document, Sep 2, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 3, 2021

Criminal Record Clearance: (e) All individuals ....pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with two staff (S1 & S2). LPA Colvin observed that S1 & S2 work at the facility but have not been associated. This is an immediate safety risk to all residents in care.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee agrees to have S1 & S2 associated to the facility prior to them working their next shift. Licensee may submit transfer request online via Guardian system, or to the Riverside office in person. Proof of submission due by Plan of Correction date of 9/3/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(l(2) · Plan of correction due date: Sep 3, 2021

Care of Persons with Dementia: (l) The following initial and continuing requirements shall be met for the licensee to lock...perimeter fence gates:(2) The licensee shall ensure that the fire clearance includes approval of...locked perimeter fence gates. This requirement was not met as evidenced by: Based on record review and interview, the Licensee did not comply with the above regulation with two gates. LPA Colvin observed the front & side gates to have electronic locks. LPA Colvin confirmed with Fire Department that locked perimeter was not approved. This is an immediate safety risk.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee agrees to have locked perimeter uninstalled until Licensee obtains both approval from CCL and Fire Department to utilize locked perimeter. LPA Colvin to submit LIC850 to Fire Department for evaluation of approval for delayed egress. Licensee to self-certify to LPA Colvin that locks have been disabled.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87216(d) · Plan of correction due date: Sep 16, 2021

Bonding: (d) No licensee shall either handle money of a resident or handle amounts greater than those stated in the affidavit submitted by him or for which his bond is on file without first notifying the licensing agency and filing a new or revised bond... This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with all residents. LPA Colvin observed the facility holds petty cash for all residents, but has an affidavit on file with CCL that they will not handle resident funds. This is a potential personal rights violation.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee to submit a new Affidavit to CCL, or to cease holding money for residents. Affidavit or statement confirming cease of holding resident funds to be submitted to LPA Colvin by plan of correction date of 9/16/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87216(a) · Plan of correction due date: Sep 16, 2021

Bonding: (a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. This requirement was not met by Based on interviews and record review, the Licensee did not comply with the above regulation with all residents. LPA Colvin observed the facility holds petty cash for all residents but does not have a Surety Bond to cover these funds. This is a potential personal rights risk to all residents.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee to obtain and submit a copy of their Surety Bond (as noted in regulation section 87216) to CCL, or to cease holding money for residents. Surety Bond or statement confirming cease of holding resident funds to be submitted to LPA Colvin by plan of correction date of 9/16/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(g)(1) · Plan of correction due date: Sep 16, 2021

Safeguards for Resident Cash...:(g) Each licensee shall maintain adequate safeguards and accurate records of cash resources...including...: (1) Records...shall include a ledger accounting (columns for income, disbursements and balance) for each resident... This requirement was not met by: Based on interview and record review, the Licensee did not comply with the above regulation with all residents. LPA Colvin observed that the Licensee did not maintain a ledger for resident funds, only receipts. This is a potential personal rights violation for all residents.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee agrees to maintain an accounting log for all resident money kept by the facility. Licensee to self-certify to LPA Colvin confirmation of this as well as provide LPA Colvin with a copy of an accoutning ledger for each resident or statement confirming ceasing handling resident funds. Plan of Correction due 9/16/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(g)(3)(C)(4) · Plan of correction due date: Sep 16, 2021

Admission Agreements: (g) Admission agreements shall specify...:(3) Payment provisions, including...: (C) Any fee that is charged...after admission... 4.A licensee shall not require, request, or accept any funds...that constitutes a deposit against any possible damages by the resident. This was not met by: Based on interviews, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin learned that R1's POA was only provided $100 of the $200 funds given to the facility for R1, due to damages hte facility charged back to R1. This was a potential personal rights violation.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee to refund $100 to R1's POA and provide proof of refund to LPA Colvin as well as submit Statement of Understanding to LPA Colvin that resident funds ("petty cash") shall not be used as security deposit. Plan of Correction due 9/16/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 16, 2021

Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports...including...: (1) A written report shall be submitted to the licensing agency within seven days of the occurrence of any of the events...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with one resident. LPA Colvin observe R1 did not have any incident reports despite numerous hospital stays. This was a potential safety risk for R1.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee agrees to review Regulation Section 87211 in it's entirety and self-certify to LPA Colvin once complete. Self-certification to also include Statement of Understanding and confirmation to abide by Reporting Requirements. Plan of Correction due by 9/16/21.