Angel's Loving Touch

Allegation investigated: Facility refused to provide a refund Facility did not accept back resident into care

On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPAs Colvin met with Administrator Yazmin Cedra. Below is a summary of the findings of the investigation: Regarding allegation "Facility refused to provide a refund": LPA Colvin reviewed the facility's Admissions Agreement for a prior resident (R1) including added optional services. LPA Colvin observed that R1's monthly expenses for July 2022 was paid in full, prior to R1 being sent out to the hospital. On July 13,2022, R1's Power of Attorney (POA) submitted notice that R1 would not be returning to the facility. R1's POA requested a refund under the section of the Admissions Agreement which states that only a 14 day notice is required (in lieu of a 30-day notice) if the resident is in the hospital with a Prohibited Health Condition. R1 was hospitalized for COVID-19, which is not considered a Prohibited Health Condition (diagnosis' meeting this criteria can be located in Title 22 Regulation Section 87615). Therefore, R1's POA was still responsible for a 30-day notice for R1, which would be from July 13, 2022 to August 12, 2022. Administrator Yazmin Cedra provided LPA Colvin Unsubstantiated with a copy of an invoice sent to R1's POA showing that no further charges would be requested from the facility past what was already paid for the month of July 2022. Therefore, based on record review and interviews conducted, the allegation "Facility refused to provide a refund" is UNSUBSTANTIATED, as there is not enough evidence to suggest that the facility owed R1's POA a refund. Regarding allegation "Facility did not accept back resident into care": LPA Colvin conducted interviews with Administrator Yazmin Cedra and others with knowledge of R1's relocation from the facility to the hospital, and R1 subsequently not returning to the facility. All interviews conducted confirmed that there was concern regarding R1 being positive for COVID-19 and having Dementia, and therefore having difficulty with isolation. LPA Colvin was unable to verify the reason for R1 not returning to the facility when R1 was ready to be discharged from the hospital, as interviews conflicted on if the facility was requiring R1's POA to provide/pay for additional care/services. Administrator Yazmin Cedra confirmed that there was a conversation regarding needing additional staff to supervise R1 during R1's quarantine period (if returning to the facility), but the Administrator states that specifics were never discussed (such as if there would be additional charges), as R1's POA elected to have R1 discharged back to home with family without prior collaboration with Administrator. Yazmin Cedra remained adamant that R1 was never declined returning to the facility from the hospital while positive with COVID-19, and that Yazmin Cedra simply discussed the difficulties this may pose and the different aspects that the family should consider. Therefore, due to lack of evidence and conflicting interviews, the allegation "Facility did not accept back resident into care" 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 Yazmin Cedra and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 16, 2022 · control 18-AS-20220808094412

Allegation investigated: Staff failed to safeguard resident's medications.

On today's date, Licensing Program Analysts (LPAs) Crystal Colvin and Chinwe Nwogene arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPAs Colvin and Nwogene met with Administrator Jazmin Cedra. Below is a summary of the findings of the investigation: Regarding allegation "Staff failed to safeguard resident's medications": LPA Colvin reviewed facility medication storage location as well as records for residents' medication. LPA Colvin additionally interviewed Administrator regarding the allegation. Administrator Jazmin Cedra denied any knowledge of any medication missing from the facility for any resident. When LPA Colvin informed her that the Department has photos of another resident's (R1) medication mixed in with other resident medication outside of the facility, Administrator Jazmin Cedra theorized that an error was possibly made when packing up medication for a resident that was discharged from the facility. LPA Colvin inquired as to how the Administrator did not notice the missing medication, and Administrator Jazmin Cedra stated that it was most likely a medication that the facility has extra of for the resident, or a discontinued medication, which is held in a sperate stored location. Substantiated LPA Colvin observed that the medication that the Department has photos of (Atorvastatin) was not listed on the Centrally Stored Medication Log for R1. Administrator Jazmin Cedra was able to pull a physician's order from R1's file showing that the medication was prescribed to R1 and put on hold pending results of tests. Based on photographs, interviews, and record review, the allegation "Staff failed to safeguard resident's medications" 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 Colvin, 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 Jazmin Cedra during the exit interview.the state’s words, verbatim · CDSS document, Jul 28, 2022 · control 18-AS-20220721143820

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jul 29, 2022

Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement was not met by: The licensee did not comply with the above regulation with 1 of 4 residents. LPA Colvin confirmed that facility staff accidentally let one of R1's medication be removed from the facility by somone other than an employee or persons responsible for R1. This was an immediate personal rights and health risk of R1.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Licensee agrees to implement a system to better document all individual bottles/containers of medication in the facility to ensure that if one goes missing, staff can be aware or confirm this immediately. Licensee to additionally submit a Special Incident Report to Licensing as well as inform R1's responsible person (if any, or if none, R1) of missing medication. Licensee to provide LPA Colvin with details of plan regarding record keeping of medications, copy of submitted Incident Report, and proof of notification to R1 and R1's responsible person (if any). Due by Plan of Correction date of 7/29/22.

Type of visit: Case Management - Deficiencies

On this date, Licensing Program Analysts (LPAs) Crystal Colvin and Chinwe Nwogene made an unannounced visit to the facility to investigate a complaint #18-AS-20220721143820. During today's inspection, LPA Colvin observed that the laundry room (which stores both medication and chemicals) was unlocked at the time of LPAs visit. Additionally, the medication cart and cabinets containing chemicals were unlocked. It is relevant to note that there is no ability to lock the laundry room door from the outside, so without the cabinets and medication cart being locked, all items were accessible. Deficiency cited. Based on observations made by LPA Colvin, the facility was cited and deficiency noted on the LIC 809D page. LPA Colvin conducted an exit interview wit Administrator Jazmin Cedra where a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 28, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 29, 2022

Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: The Licensee did not comply with the above regulation with one area of the facility. LPA Colvin observed the medication cart and cabinets containing chemicals in the laundry room to be unlocked and accessible. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Licensee agrees to conduct staff re-training on safe storage of hazardous materials, such as medication and chemicals. Licensee to provide LPA Colvin with proof of staff training by Plan of Correction date of 7/29/22

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was granted entry and met with Administrator Yazmine Cerda, who was informed of the purpose of the visit. At the time of visit there was 3 staff and 6 residents present. The facility currently has zero positive or suspected Covid-19 cases. During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings and a single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place through a online database system to track resident records which was shown to LPA by the facility Technical Support individual (TV). The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. Common areas such as dining rooms and living rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces. LPA advised Administrator to provide the department with a copy of the facility Mitigation plan that was previously submitted to the department. During the visit LPA was informed about a new Hospice admittance for R1 on 5/13/2022 and was able to provide a signed hospice admittance letter to LPA. LPA also requested an LIC500 and noticed S1 and S2 where not associated to the current facility # 331881115 but they were associated to the previous facility that went under a change in ownership called “Sacred Heart”. LPA will assure that all staff where transfered to the new facility number and that facility "Sacred Heart" was properly closed. LPA also spoke with facility TV. Per Administrator, technical support is at the facility once a month but is not associated as a staff member because his role is to assist with documentation and their online program. LPA was able to confirmed their clearance through the department and advised Administrator to have them associated to the facility. There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to facility administrator, Yazmine Cerda.the state’s words, verbatim · CDSS document, May 18, 2022

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.