Garden of Eden Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 3:52 pm to conduct an unannounced annual visit. LPA met the Administrator Regina Holmes-Otto at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) residents (2 ambulatory and 4 non-ambulatory residents) with 2 residents in care (1 ambulatory, 1 non-ambulatory). The facility has an approved Hospice Waiver for 4 residents. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: The facility temperature read at 73 degrees. The facility consists of 3 resident bedrooms, and 2 bathrooms, 1 Administrator bedroom, living room, kitchen, and backyard. The bedrooms are furnished with lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 120 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the hallway and inaccessible to the resident. The facility has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order. Personnel Records-Training: There are no staff records available at this time. The Administrator is currently the only staff. Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, client rights, and admissions agreements. (Continued on LIC809-C) (Continued from LIC809) Client Rights-Information: The facility has client rights information posted in the facility. Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available. Health- Related Services: The facility has a medication logbook; the facility documents the resident’s medication and in is compliance with physician’s orders and regulations. Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff, visitors and residents in care. The last fire drill was conducted 08/23/23. The facility has emergency supply of food and water. Summary: No deficiencies have been observed at this time. An exit interview was conducted, along with a copy of this report was provided to the Administrator Regina Holmes-Otto and her signature on this form confirms receipt of these rights.the state’s words, verbatim · CDSS document, Oct 18, 2023

Allegation investigated: Staff did not ensure that resident was provided with activities while in care. Licensee is making false claims regarding services provided by the facility. Staff confined resident to their bed while in care. Staff emotionally abused resident while in care. Staff prohibited resident for using the telephone while in care.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA met with Licensee, Regina Holmes- Otto 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 the resident was not provided with activities at the facility. LPA spoke with Resident #1 (R1) who stated they were not provided with activities at the facility, and stated they stayed in their bed. LPA spoke with licensee who stated they had tv’s for residents to watch and outdoor area for residents to go in, they also showed the LPA the activities they have for the residents to engage in. Therefore, the allegation that the residents were not provided with activities while in care is unsubstantiated as the allegation was unable to be corroborated. Unsubstantiated Findings that are substantiated mean that the preponderance of the evidence standard has been met. Deficiencies were cited under California Code of Regulations Title 22. The plan of correction was documented and created with the licensee. An exit interview was conducted where this report, 9099-D page and appeal rights were provided to the licensee, Regina Holmes- Otto. It was alleged that the facility was making false claims about services provided to the residents. It was alleged the licensee was claiming to be the resident’s nurse and told the resident’s responsible party not to call the hospice nurse and stated “don’t call hospice, I am the one in charge here”. The resident was interviewed who stated that the licensee did claim they used to be a nurse and stated they would take care of them. However, they could not recall if the licensee had denied hospice services. LPA spoke with the licensee who stated she used to be a nurse, but denied acting as a nurse for her residents and denied telling the the resident’s responsible party not to call hospice. Therefore, the allegation was unable to be corroborated and the allegation is unsubstantiated. It was alleged that staff confined resident to their bed while in care. It was alleged the licensee had stated R1 was “bedridden” and could not get out of bed and therefore kept R1 in bed. Upon review of R1’s LIC602 it was found R1 was not indicated as bedridden but instead stated “non ambulatory”. Licensee was interviewed who also stated R1 was not bedridden. They stated the pre appraisal filled out my R1’s responsible party stated R1 was “In bed most of the time”. LPA reviewed the preappraisal which corroborated the information. The licensee denied confining R1 to their bed. R1 was interviewed who stated they had not been taken out of bed by the licensee. It was also alleged the resident had redness on their rear as a result of not being moved out of bed. LPA interviewed staff at R1’s new facility. The staff stated they observed redness on the resident’s rear upon admission. They stated they did not believe this was due to neglect, as it had “gone away” the next day. The licensee was interviewed who stated the resident had redness from time to time, but would apply cream for the resident where the redness would go away. Therefore the allegation that the resident was confined to their bed was unsubstantiated. It was alleged the staff would emotionally abuse the resident. It was alleged that the licensee had told the resident they were “going to die” and would “ignore” the residents requests. LPA interviewed the residents who stated the administrator would ignore the resident when they would ask for something, and be “rude” to them. LPA interviewed the licensee who denied the allegations. LPA interviewed three identified witnesses to the licensee’s behavior. All three witnesses stated the licensee had “rude” demeanor but stated they had not witnessed this directed toward the residents at the facility. The LPA was unable to corroborate the allegation that the staff emotionally abused the resident, therefore it is unsubstantiated. It was alleged the resident was prohibited from making phone calls while at the facility. LPA interviewed the resident who stated they were told by the licensee that they could not use the phone as it was the “business phone”. LPA interviewed the licensee who stated they would let the resident make phone calls and receive phone calls. LPA spoke with R1's responsible party who stated they had spoken with the resident through the facility phone number. Therefore, the allegation was unable to be corroborated and is unsubstantiated. Findings that are unsubstantiated mean that although the allegations are valid, the preponderance of the evidence standard has not been met. An exit interview was conducted where this report was reviewed and provided to Licensee, Regina Holmes-Otto.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 18-AS-20230807084041

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87456(a)(4) · Plan of correction due date: Aug 23, 2023

(a)A plan for incidental medical...care shall be developed...(4)The licensee shall assist residents with self-administratered medications as needed. Based on records and interviews the licensee failed administer medication to R1 and document this on required forms. This poses an immediate health, safety or personal rights risk.the state’s words, verbatim · CDSS document, Aug 22, 2023

Plan of correction: The licensee agreed to administer medications to all residents as prescribed and document this for residents on centrally stored list. The POC is to send the LPA a written statement of this, and send a completed centrally stored list for the resident by the POC due date.

Allegation investigated: Staff are mismanaging resident's medication(s).

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Licensee/ Administrator, Regina Holmes-Otto, who was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations, and conducted records reviews. It was alleged the facility was mismanaging the resident's medications. LPA interviewed the licensee who stated that they had provided another resident's medications to Resident #1 (R1) when they were discharged from the facility. Licensee stated they had R1's medication as well as Resident #2 (R2)'s medication on a table in the kitchen, and stated they had grabbed one of R2's medications and placed them with R1's medications by mistake. LPA observed R2's medication on the kitchen table during the time of the visit. LPA had licensee lock the medications immediately. Therefore, the allegation that the licensee mismanged the resident's medication is substantited. Substantited findings were cited under California Code of Regulations Title 22. Plan of correction was created with licensee. An exit interview was conducted where this report was reviewed and provided to licensee Regina Holmes- Otto, along with deficency page, 811 and appeal rights. Substantiatedthe state’s words, verbatim · CDSS document, Aug 11, 2023 · control 18-AS-20230807084041

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Aug 12, 2023

(h)...medications which are centrally stored: (2)...shall be kept in a safe and locked place...This requirment was not met as evidenced by: Based on interview and observation it was found that centrally stored medication for R2 was unlocked and provided to R1 upon discharge. This poses an immediate health safety or personal rights risk.the state’s words, verbatim · CDSS document, Aug 11, 2023

Plan of correction: The licensee agree to send the LPA a written statement stating that they will ensure all medication is kept locked and will keep documentation for medication taken with a resident upon discharge. This POC is due to the LPA by the POC due date.

The state marks this report as 3 pages; the online copy we transcribed has 2. 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 the facility to conduct an annual inspection with an emphasis on infection control. LPA Gardner met with Licensee Holmes-Otto. Present in the facility during time of visit were 2 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. LPA Gardner discussed infection control practices and procedures with Ms. Holmes-Otto. An exit interview was conducted and a copy of this report and provided to Ms. Holmes-Otto.the state’s words, verbatim · CDSS document, Oct 15, 2021