Lifestyle Home Care

Allegation investigated: Staff neglect resulted in resident #1 (R1) sustaining an unstageable pressure injury. Staff did not notify resident's authorized person of a change in health condition.

On 09/29/2023 at 01:00 PM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott met with Licensee/Administrator Mary Mateas and staff Steven Mateas at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit. The Department investigation included interviewing staff, residents, collecting pertinent records and records review. Based on the evidence collected during the investigation, the Department staff determined that there was corroborating evidence that Resident 1 (R1) sustained a stage 3 pressure sore while in care (Allegation #1). Department staff reviewed R1’s medical records. Medical records show that on 04/03/2022, R1 was transported to the hospital and unstageable pressure ulcer in R1’s sacral area was observed on hospital admission and R1 was later diagnosed with “Unstageable Sacral Area on Admission. *** Continuation in LIC9099 *** Substantiated R1 was admitted to the facility in 2019. R1 was considered non-ambulatory and used a wheelchair for mobility. R1 was paralyzed on right side of body and had limited mobility. Physician assessment in facility records indicates that R1 was incontinent and needed staff assistance with toileting needs, including changing of incontinent briefs. In addition, R1 needed care and assistance with activities of daily living such as bathing, dressing, and eating. R1 did not have a history of skin breakdown, according to assessment. Per investigation, R1 did require two people for transfer. Per staff interviews, something described as a “small scratch” was observed on R1’s sacral area on March 31, 2022, several days prior to being admitted to the hospital. According to facility documentation, the area was described on April 1, 2022, as “red (irritation).” Facility staff did not seek medical assistance regarding these observations. Rather, facility staff treated the “scratch” with “diaper cream” and Neosporin. In addition, facility staff reported that R1 would spend most of the day in a recliner or wheelchair. Investigation revealed that on April 3, 2022, R1 was admitted to the hospital due to vomiting. Upon admission, medical records show that R1 was diagnosed with an unstageable pressure injury to sacral area, with a Stage 1 pressure injury to mid upper back and abrasions to right hand and right knee. Facility records nor staff interviews revealed observations of pressure injuries as diagnosed. Based on the Department investigation, it is concluded that there is sufficient evidence to substantiate allegation of staff neglect of R1. It was evident that R1 required staff assistance with activities of daily living, including incontinent care. However, it was found that facility staff failed to provide the services needed by R1 to meet R1 needs. *** Continuation in LIC9099C *** As a result, R1 sustained an unstageable pressure injury to sacral area while in care. 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 immediate Civil Penalty in the amount of $500.00 was assessed. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(f). Regarding allegation #2, Staff did not notify resident's authorized person of a change in health condition, LPA Brown determined that there was corroborating evidence that staff did not notify R1’s authorized person, the Inland Regional Center (IRC), of a change in health condition. Interview with Staff 1 (S1) indicated that Staff 2 and Staff 3 did not report a change in health condition specifically R1’s pressure injury to S1. In addition, an interview with IRC Consumer Services Coordinator revealed that staff did not notify them of R1’s change in health condition, and specifically indicated that no pressure injury was reported to them, and they only found out of the reported change of health condition from the hospital. Based on the information and interviews gathered the allegation Staff neglect resulted in resident #1 (R1) sustaining an unstageable pressure injury (Allegation #1) and Staff did not notify resident's authorized person of a change in health condition (Allegation #2), are 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. Please see LIC9099D for deficiencies cited. An exit interview was conducted where this report (LIC9099), LIC9099D, LIC421IM and Appeal Rights were discussed, and a copy was provided to Licensee/Administrator Mary Mateas and staff Steven Mateas at the conclusion of the visit. Evidence shows that the facility staff called American Medical Response (911) on April 3 for R1’s complaint of Nausea and Vomiting. Staff interviews revealed that R1 was not exhibiting any unusual behavior or complaining of pain. Moreover, it was reported that facility staff monitored R1’s blood pressure and oxygen levels until emergency services arrived. There is insufficient evidence to prove that Staff did not seek medical attention for resident in a timely manner. The evidence also demonstrates that the facility acted appropriately by calling AMR when R1 complaint of nausea/vomiting and monitored R1’s blood pressure and oxygen levels. Therefore, based on the evidence obtained during the Department's investigation, the allegation of Staff did not seek medical attention for resident in a timely manner is unsubstantiated at this time. Although the allegation Staff did not seek medical attention for resident in a timely manner may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report (LIC9099) was discussed and provided to Licensee/Administrator Mary Mateas and staff Steven Mateas.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 56-AS-20220407125449

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 30, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following…(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency… This requirement was not met as evidenced by: Based on interviews & records review, it was found that Licensee did not ensure R1 received the care, supervision & services to meet their needs. On April 3, 2022, R1 was admitted to the hospital and was diagnosed with an unstageable pressure injury to their sacral. However, it was found that treatment and care for the injury was not being provided as needed. This violation of regulation posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: The licensee stated to train all staff on CCR 87468.2 (a) (4) and submit Training Log to LPA Brown by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 30, 2023

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided... This requirement is not met as evidenced by: Based on observations, interviews and record review, the Licensee did not comply with section cited above by not reporting to R1's physician and R1's responsible person the observed changes or deterioration of R1's physical health condition and by not ensuring that such changes are documented which poses an immediate health, safety, and personal rights risks to resident in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: The licensee stated to train all staff on CCR 87466 and submit Training Log to LPA Brown by POC due date.

Type of visit: Case Management - Deficiencies

On 09/29/2023 at 01:00 PM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott met with Licensee/Administrator Mary Mateas and Steven Mateas at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to initiate a Case Management Office Visit. LPAs Brown and Wolcott explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation. During the Inland Regional Center (IRC) facility visit on 04/25/2022, IRC staff reported that Staff 2 (S2) has not received Direct Support Professional (DSP) – I certification which should have been obtained 01/31/2020 and Staff 3 (S3) has not received the required Direct Support Professional (DSP) – II certification which should have been obtained 04/30/2022. LPA Brown will be issuing a citation for this deficiency as this poses immediate risk to residents in care. In addition, IRC staff reported that during their visit, it was observed that no Physician Oder on file for both “Calmoseptine” and “Neosporin” for Resident 1 (R1) and its administration were not recorded on the Medication Administration Record (MAR). Moreover, during the IRC Visit, they observed that there’s no Physician Order, Medical Documentation or Plan on file to support that the facility staff were required to assist with R1’s glucose testing and monitoring. Also, per IRC’s review of documents, the administration of glucose testing was not recorded in MAR and no documentation was available to support that the S2 or S3 received training by licensed professional for glucose testing. IRC staff also observed during the visit that there is a prescription on file at the facility for R1 to take Ensure or Glucerna one (1) can twice per day, but it was also observed that the administration of Ensure or Glucerna is not being documented in the MAR. LPA Brown will be issuing a citation for these deficiencies as this poses immediate risk to residents in care. An exit interview was conducted where this report (LIC809), LIC80D and Appeal Rights were discussed and provided to Licensee/Administrator Mary Mateas and staff Steven Mateas.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c)(2)(B) · Plan of correction due date: Sep 30, 2023

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual... (2) This training shall be...(B) Importance and techniques of personal care... This requirement is not met as evidenced by: Based on observations, interviews and record review, the Licensee did not comply with section cited above by having S2 and S3 worked at the facility without the required initial/annual training which poses immediate health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee stated to submit Proof of Required Trainings of all staff to LPA Brown by POC due date. Licensee stated to submit a Signed Statement of Understanding on CCR 87411(c)(2)(B) by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(6) · Plan of correction due date: Sep 30, 2023

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications...(6) The licensee shall be responsible for assuring that a record... This requirement is not met as evidenced by: Based on observations, interviews and record review, the Licensee did not comply with section cited above by not documenting in R1's Medication Administration Record (MAR) the administration of Calmoseptine and Neosporin, the administration of glucose testing was not recorded in MAR and Ensure or Glucerna per prescription issued which poses immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee stated to train all staff on CCR 87465(h)(6) and submit Training Log to LPA Brown by POC due date. Licensee stated to submit Signed Statement of Understanding on CCR87465(h)(6) to LPA Brown by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Sep 30, 2023

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by allowing Staff #2 (S2) to perform blood glucose testing to Resident #1 (R1) which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee stated to train all staff on CCR 87628(a) and will submit Training Log to LPA Brown by POC due date. Licensee stated to not allow staffs to perform blood glucose testing to residents and will only allow appropriately skilled professional to perform blood glucose check and will submit signed Statement of Understanding on CCR 87628(a) to LPA Brown by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Mary Mateas, Administrator and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) non-ambulatory resjdents and a current census of (3). Hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Facility has no outdoor bodies of water. Facility has furniture in good repair for residents in care. Facility has a covered outdoor area and gated front and back yard. LPA inspected the kitchen. The refrigerator temperature is maintained at 40 degrees F. Hot water temperature is maintained at 112 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of residents in care. A monthly menu is posted in the kitchen. Facility has sufficient cups, plates, and utensils for residents in care. Facility food is stored in a safe and healthful manner. LPA inspected client bedrooms. Bedrooms are equipped with mattresses, nightstands, pillows, chairs, and storage space. Bedrooms have sufficient linen and lighting. LPA inspected client bathrooms. Bathrooms are equipped with handrails and operating in safe and sanitary conditions. Bathrooms hot water temperature is maintained at 105 degrees and 110 degrees F. LPA observed the facility is equipped with operating carbon monoxide alarms and fully charged fire extinguisher. Facility has operating telephone service on the premises. Posters such as personal rights, Licensing complaint contact number, Ombudsman contact number, emergency phone numbers are posted in a common area. Emergency drill was conducted on 7/06/23. Disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to residents in care. Sharps are kept locked and inaccessible to residents in care. Client medications are kept in a safe and locked cabinet inaccessible to clients in care. All medication are labeled and administered as prescribed. All staff files reviewed had First Aid Certifications, fingerprint clearances/exemptions, health screenings, training, employee applications. All client records reviewed had admissions agreements, medical assessment, needs service plans, record of personal property. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. No deficiencies were cited during today's visit. An exit interview was conducted, where this report (LIC809) was discussed and a copy of report with appeal rights was provided to the Administrator at the conclusion of the visitthe state’s words, verbatim · CDSS document, Jul 28, 2023

Allegation investigated: Misuse of resident's funds

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding an allegation of misuse of resident's funds. LPA Prieto met with Administrator Mary Mateas and discussed the elements of the allegations. LPA Prieto obtained documentation from Mary Mateas regarding resident #1 (R1) in question. Documentation will show that R1 has a separate payee that is not the administrator of the facility or association to the facility. R1 receives financial benefits directly toward R1's payee. Documentation gathered, related towards the facility, are those related to rent and finances related to R1s stay at the facility. R1 is handling their own financial matter through outside agencies and to the placement agency party. Based on the information obtained there is not enough evidence that facility misuses resident's funds. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 2, 2022 · control 56-AS-20220728150851

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: Required - 1 Year

Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA met with Mary Mateas and explained the purpose of the visit. 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 proper signs throughout the facility, 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. 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 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 illnesses. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or 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, May 16, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 04/08/2022 at 08:45 AM to commence a health and safety check. LPA Brown identified herself and discussed the purpose of the visit with Staff 1. Administrator Maria Matias was contacted and arrived at the facility and LPA Brown explained the purpose of the visit due to complaint # 56-AS-20220407125449. Residents in care were present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA Brown observed no health and/or safety hazards inside the facility. LPA Brown inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Brown observed sufficient staff present at the facility to provide care. LPA Brown inspected facility food supplies and observed three (3) days supply of perishable and seven days (7) supply of non-perishable food. The needs of the residents in care appear to be met during this inspection. An exit interview was conducted where this report (LIC809) was discussed and provided to Administrator Maria Matias.the state’s words, verbatim · CDSS document, Apr 8, 2022