Mama Angelina Coconocho

Type of visit: Required - 1 Year

On 10/17/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Licensee, Maria Gonzalez who was informed of the purpose of the visit. At the time of visit there was 1 staff and 5 residents present. LPA toured the facility inside and out with Maria Gonzalez. Tour included: Kitchen; LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the census. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen cabinet, available only to authorized individuals. Trash cans has tight-fitting lids. Dishwasher is used to clean and sanitize dishes. Fridge, Freezer, and all need appliances were present and shown to be in working condition and clean. Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 77 degrees Fahrenheit. Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items. Medication; LPA observed medications were labeled and stored in separate bins inside of a locked kitchen cabinet and are distributed according to physician orders. The first aid kit was complete. Continue on LIC809-C Continued from LIC809. Bathroom; LPA toured two #2 out of #2 resident’s bathrooms and observed bathrooms to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents in care. Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility. Garage; LPA tour the garage and observed garage to be clean and not cluttered. Laundry; Laundry supplies are stored away in the garage, inaccessible to clients, washing machine and dryer are all in good repair and sufficient for the census. Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction. No bodies of water were observed. Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and Freezer is large enough to accommodate required perishable food. Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three #3 staff and #3 residents' records were reviewed. All required postings were posted near the entryway and throughout the facility. The administrator certificate expires on 9/26/2024. Interview; one #1 staff and three #3 residents were interviewed. No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Maria Gonzalez.the state’s words, verbatim · CDSS document, Oct 17, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 10:40 AM, LPA was met by Caregiver Michelle Fisher and explained the purpose of the visit. Present in the facility during time of visit were two (2) staff as well as six (6) residents. Licensee Maria Gonzalez arrived during the inspection. There are currently no cases of COVID-19 within the facility. During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient signage throughout the facility, insufficient 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, PPE supplies are maintained at the facility, cleaning and disinfection provisions are in adequate quantities, and that staff are not trained in the proper use and disposal of PPE and 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. The facility also maintain a plan to monitor resident(s) 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 illnesses. Based on the observations made during today’s visit, four (4) Technical Assistance Advisories, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview to review this report was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 31, 2022

Allegation investigated: Lack of supervision resulting in resident leaving the facility

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Maria Gonzalez. Below is a summary of the complaint investigation findings: Regarding allegation "Lack of supervision resulting in resident leaving the facility": LPA Colvin confirmed through interviews that on 7/4/22, resident (R1) eloped from the facility without the knowledge of facility staff. LPA Colvin confirmed through record review that R1 is diagnosed with Dementia and has a history of wandering behavior. Despite these facts, LPA Colvin was informed by the Administrator that R1 eloped through the facility during a brief period of time after dinner, in which R1 usually retreats to their room. During this time, R1 left the facility via their bedroom window. LPA Colvin was additionally informed that R1 has lived at the facility for over two years and has never eloped from the facility. Additional interviews/hospital records confirm the time that R1 was picked up by local law enforecement and brought to the hospital (around 6pm). Unsubstantiated These additional interviews/hospital records additionally confirm that R1 had left the facility through their bedroom window. Since evidence supports the Administrator's recollection of the event, the circumstances surrounding the elopement do not suggest a lack of supervision by staff, as R1 exited through a window (which is low in the wall and is feasible for R1 to have exited from) in their bedroom during a brief period of time where staff did not have line of sight on R1, and it was normal for R1 to be in their private bedroom at this time. Additionally, R1 had no prior elopements from the facility in the last two years since admission. R1's elopement from the facility was unusual in R1's established behavior at the facility as well as the method used to exit the premises. Therefore, based on interviews, observations, and hospital records, the allegation "Lack of supervision resulting in resident leaving the facility" 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 Maria Gonzalez and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 22, 2022 · control 18-AS-20220715115207

Type of visit: Case Management - Deficiencies

On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #18-AS-20220715115207. During today's inspection, LPA Colvin observed the following deficiencies, which was reviewed with Administrator Maria Gonzalez: Care of Persons with Dementia - LPA Colvin observed while at the facility that the auditory alarms on the front door and back door of the facility were switched to the "off" position, and were not alerting staff as to when the door was opened. The facility retains residents with Dementia, including resident (R1) who recently eloped from the facility on 7/4/22. Deficiency cited. Additionally, LPA Colvin observed that R1, who is diagnosed with Dementia, does not have a Physician's Report dated any more recently than June of 2021. The facility is required to have these reports updated at least annually for persons with Dementia. Deficiency cited. Fire Safety - While LPA Colvin was inspecting the front door alarm, LPA Colvin observed that staff had locked the front door using the deadbolt, which was only able to be unlocked from the inside of the facility with a key. This is an dangerous fire hazard to the residents and staff, as in the event of an emergency, they would not be able to quickly exit the front door unless they had the key on hand. Deficiency cited. Fire safety violations result in an immediate civil penalty in the amount of $500. Visitor Policy - When LPA Colvin walked up to the facility's front door from the outside, LPA Colvin observed a posted Visitation Policy/Hours, which limited visitation to 9:30am - 5:30pm on Monday - Friday, and 10am - 4pm on the weekends. LPA Colvin did observe an addendum to the hours underneath, which read that these hours could be flexible for family members. This is a violation of resident's rights to visitors, as the hours listed during the week are common working/business hours, and the hours on the weekend are even more severely restricted. Deficiency cited. Reporting Requirements - LPA Colvin observed through review of records (prior to today's inspection back at Community Care Licensing Regional Office that the facility has not submitted any Special Incident Reports (SIRs) since obtaining their License, and only submits Death Reports. The Licensee is required to submit an SIR for any event which poses a risk to residents' health or safety, including elopements from the facility. R1 eloped from the facility on 7/4/22 and was subsequently put on a psychiatric hold (51/50) at the hospital, neither of which were reported to Licensing by the facility. Deficiency cited. Personal Accommodations - While LPA Colvin was examining R1's bedroom, LPA Colvin attempted to turn on a light in order to see better. LPA Colvin observed that nothing happened when flipping the light switch, so LPA Colvin looked around and found a small lamp on a bedside table. LPA Colvin picked up the lamp to examine how to turn it on, and observed that it was not plugged in to anything. LPA Colvin still attempted to turn the light on (in case of batteries) but observed that nothing happened. There is no light available for use in R1's bedroom. Deficiency cited. Based on observations and record review conducted by LPA Colvin, the facility was cited and deficiencies noted on the LIC 809D pages. LPA Colvin conducted an exit interview wit Administrator Maria Gonzalez where a copy of this report, LIC 809Ds, LIC 421IM, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 22, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jul 25, 2022

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation with at least one area of the facility. LPA Colvin observed that the front door was locked with a deadbolt that is only able to be unlocked with a key. This is an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2022

Plan of correction: Licensee agrees to have the deadbolt removed and to provide LPA Colvin with photographic proof of removal. The Licensee may choose to replace the deadbolt with one which can be unlatched from the inside without a key. Photos to be provided to LPA Colvin by Plan of Correction date of 7/25/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(j) · Plan of correction due date: Jul 25, 2022

Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on observation, the Licensee did not comply with the above regulation with two exit doors. LPA Colvin observed both the front door and back door of the facility to have their auditory alarms turned off. LPA Colvin also tested the doors to confirm. This is an immediate safety risk to Dementia residents.the state’s words, verbatim · CDSS document, Jul 22, 2022

Plan of correction: Licensee agrees to obtain additional alarms (Licensee has one which is used at night which residents do not notice and remove) which Licensee and LPA agree are suitable to meet Regulation Requirements. Licensee to provide LPA Colvin with photos of where alarms are placed. Photos due by 7/25/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 25, 2022

Reporting Requirements: (a) Each licensee shall furnish...reports...including... the following: (1) A written report shall be submitted ...within seven days of...(D) Any incident which threatens the welfare, safety or health of any resident, such as... unexplained absence of any resident. This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one occurance. LPA Colvin confirmed that no report was submitted for R1's elopment from the facility on 7/4/22. This is an immediate safety risk of all residents, as the facility has never submitted a report to Licensing.the state’s words, verbatim · CDSS document, Jul 22, 2022

Plan of correction: Licensee agrees to submit an incident report regarding R1's elopment from the facility and subsequent hospitaliztion. Licensee additionally agrees to review Title 22 Regulation section 87211 regarding Reporting Requirements. Licensee may self-certify to LPA Colvin once complete along with a Statement of Understanding regarding what types of incidents must be reported to Community Care Licensing. Incident Report for R1, self-certitifcaiton of Regulation Section 87211 review, and Statement of Understandin due by Plan of Correction date of 7/25/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(11) · Plan of correction due date: Aug 5, 2022

Personal Rights of Residents in All Facilities: (a) Residents...have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours... This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation. LPA Colvin observed Visitor Hours posted outside the facility which were unreasonably restrictive. Additionally, the posted hours are not what is reflected in the facility's Admissions Agreement. This is a potential personal rights violation of all residents.the state’s words, verbatim · CDSS document, Jul 22, 2022

Plan of correction: Licensee agrees to remove the posted visitor policy and provide LPA Colvin with photographic proof of removal. Licensee additionally agrees to send a notice to all families/recent visitors (within last 60 days) of residents regarding recention of posted visitation policy. Licensee may uphold visitation policy that is stated in Admissions Agreement, though provisions and considerations must be made with visitors if they cannot visit during regular hours. Photograph and copy of notice to be provided to LPA Colvin by Plan of Correction date of 8/5/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Aug 5, 2022

Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least on resident. LPA Colvin observed that R1's most recent Physician's Report is dated 6/11/21. R1 is diagnosed with Dementia. This is a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Jul 22, 2022

Plan of correction: Licensee agrees to have R1 seen by their Primary Care Physician (PCP) and have a new Physician's Report completed. Licensee additionally reccomended to conduct self-audit to ensure no other residents are overdue for a new Physician's Report. Licensee to provide LPA Colvin with a copy of R1's updated Physician's Report, or appointment date with Statement of Understanding that Physician's Report is to be updated at this time, by Plan of Correction of Date of 8/5/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(3)(B) · Plan of correction due date: Aug 5, 2022

Personal Accommodations and Services: (a) Living accommodations...shall be related to the facility's function...The following provisions shall apply: (3) Equipment and supplies necessary...licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident...a lamp, or lights sufficient for reading... This requirement was not met by: Based on observation, the License did not comply with the above regulation with one resident. LPA Colvin observed no operational light source in R1's room other than the bedroom window. This is a potential personal rights violation of R1.the state’s words, verbatim · CDSS document, Jul 22, 2022

Plan of correction: Licensee had staff replace the lamp in R1's bedroom during LPA Colvin's inspection. Licensee agrees to review Title 22 Regulations Section 87307 regarding what furniture and supplies are to be provided to residents in each bedroom. Licensee may self-certify once complete. Due by 8/5/22.

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 Caregiver Leonardo Janolino. Present in the home during time of visit were 6 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 Mr. Janolino. During the inspection LPA Gardner observed medication left out on the counter in the kitchen not secured by a lock in a safe place, and a Type A deficiency was issued. An exit interview was conducted and a copy of this report, was reviewed with and provided to Mr. Janolino along with the LIC809-D, and Appeal Rights.the state’s words, verbatim · CDSS document, Oct 11, 2021