Majintin Ville

Allegation investigated: Staff failed to administer resident's medications as prescribed Staff are not ensuring resident's hygiene needs are met

Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to initiate a complaint investigation for the allegations listed above. LPA Gardner met with Caregivers Carmelita McNeff, and Emenita Pacia and then toured the facility. Administrator Verly Frias arrived while LPA was inside the facility. LPA informed staff of the purpose of the visit and the elements of the allegation. LPA conducted a record review of Resident One (R1)'s file, interviewed R1 (via telephone), and interviewed staff. It was alleged that staff do not pick up medications for R1 and do not provide the medications to them. Substantiated It was then alleged that R1 was not being taken to his follow up appointments, and further, staff were not assisting R1 with meeting their medical needs. LPA reviewed documents provided by the facility and found that R1 was admitted to the hospital for contracting COVID-19 on May 9, 2023, and prescribed medication to handle the diagnosis. R1 continued to receive medical care for an undiagnosed condition. Prior to that, the facility provided the most recent After Visit Summary dated March 3, 2023 which noted no additional follow-up visit was scheduled; therefore, there was no additional follow-up for the facility to provide. Thus, the allegation was Unsubstantiated. It was then alleged that the facility was not feeding R1. Interview with R1 and staff indicated that R1 was fed, and there was no concern with R1 not having enough food. Thus this allegation was Unsubstantiated, as a result. A finding of UNSUBSTANTIATED means that 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 where a copy of this report was discussed and provided. Interview with staff revealed that medications are picked up for R1 by their friend, and delivered to the facility. LPA inspected the Medication Administration Record (MAR), and; although complete, when questioned, staff advised that R1 was not getting their medication as prescribed. Thus this allegation was Substantiated. It was then alleged that staff do not assist R1 with hygiene and do not help them bathe. Interview with staff indicated that R1 was difficult to bathe, and would often refuse. Staff interview revealed that R1 should be afforded baths, but due to R1's refusal and behavior, none are offered. R1 is; however, afforded a bed bath once in awhile. Thus, this allegation was Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Thus the facility was cited per Title 22. An exit interview was conducted where a copy of this report was discusses and provided along with copies of the LIC9099D, and Appeal Rights.the state’s words, verbatim · CDSS document, May 17, 2023 · control 18-AS-20230512163605

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 24, 2023

Incidental Medical and Dental Care: (a) A plan for incidental medical..shall be developed by each facility. The plan shall encourage routine medical ..provide for assistance in obtaining such care..(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not being met as evidenced by: Based on interview, LPA discovered that staff were not assisting with R1 with receiving their medications nor in administrating them. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Licensee to develop a plan to provide R1 with their medications, as well as conduct in-service training for staff on the cited regulation. Proof of such is to be provided to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: May 24, 2023

Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition ..for the elderly shall have all of the following personal rights:(8) To be free from neglect, .. or sexual abuse. This requirement was not being met as evidenced by: Based on staff interview, LPA found that R1 was not being afforded baths by staff. This is a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Licensee agrees to conduct in-service training on the cited regulation (Personal Rights) and provide proof of training to LPA by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Verly Frias and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Verly Frias, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and 2 of 3 resident bathrooms were stocked with hand soap and paper towels. LPA Colvin observed the bathroom in resident room #3 to have paper towels but no hand soap. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note during today's inspection. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the front of the facility where guests are screened, as well as in the resident bathrooms. LPA Colvin observed the facility have an adequate supply of PPE. LPA Colvin went over the various recommended training for facility staff with Administrator Verly Frias in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Verly Frias informed LPA Colvin that at this time staff have only been trained on donning/doffing PPE. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. LPA Colvin will be providing Verly with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. Additionally, LPA Colvin observed 1 of 3 staff (S1) present to not be wearing any type of face covering. At this time, face coverings are still required in all residential facilities. LPA Colvin will be issuing a TA Advisory Note for 1 of 3 staff to not be wearing a face covering. LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Verly Frias confirmed that residents are being screened daily. LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors and staff are being screened for symptoms prior to entering the facility. An exit interview was conducted with Administrator Verly Frias and a copy of this report and LIC9102 TA Advisory Notes were provided.the state’s words, verbatim · CDSS document, May 16, 2022

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Office

An Informal Meeting was conducted today via Zoom due to COVID-19 in order to discuss recent concerns and facility's operation. Persons present at today’s meeting were: Licensing Program Manager (LPM) Joel Esquivel, Licensing Program Analyst (LPA) Crystal Colvin, and Licensee/Administrator Verly S. Frias. Below are the topics that were addressed during the Informal Meeting tele-visit: Reporting Requirements Training Records for Staff Bedridden Clearance Facility's Options Regarding Resident Currently Awaiting Hospital Discharge Retaliation for Complaints History of Facilities (Cathedral Manor & Majintin Ville) LPA Colvin will additionally be issuing the facility a deficiency for the facility's consistent failure to report events concerning residents' health and well-being to Community Care Licensing. Additionally, LPA Colvin will be citing a deficiency for false statements due to the Licensee having possession of blank signed training certificates, which matches those of staff on file (observed by LPA Colvin on 8/27/21 visit). LPM Joel Esquivel and LPA Crystal Colvin offered Licensee Verly S. Frias the Technical Support Program (TSP) Assistance. The Licensee declined the TSP Program at this time. An exit interview was conducted and a copy of this report along with LIC809D with deficiencies noted, and appeal rights were provided via email to Licensee/Administrator Verly S. Frias for signature.the state’s words, verbatim · CDSS document, Aug 31, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Sep 1, 2021

False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met by: Based on observations and record review, the Licensee did not comply with the above regulation with staff training certificates. LPA Colvin observed the facility to be in possession of blank signed training records. This is an immediate safety risk to residents.the state’s words, verbatim · CDSS document, Aug 31, 2021

Plan of correction: Licensee agrees to discard the certificates in question and ensure that all training documents for staff are legitimate and verifiable. No further Plan of Correction required.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Sep 7, 2021

Reporting Requirements: (a) Each licensee shall furnish...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... This requirement was not met by: Based on record review, the Licensee did not comply with the above regulation. LPA Colvin observed that no incident reports have been submitted to Licensing since July 2020. This is a potential safety risk for all residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2021

Plan of correction: Licensee to submit to LPA Colvin any incident reports from August 2020 to current date, to ensure that they are reviewed and logged. Licensee agrees to submit reports for all reportable incidents (according to Title 22 Regulations) to Licensing in timely manner. Plan of Correction date is 9/7/21.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to investigate a complaint (#18-AS-20210825090919). During LPA Colvin's review of records at the facility, LPA Colvin observed some additional deficiencies. LPA Colvin met with Administrator/Licensee Verly Frias and advised Verly of the purpose of the visit. Below are the issues that were discussed: Current Staff Training - LPA Colvin reviewed facility files and observed that prior resident (R1) was bedridden and had a G-Tube (gastronomy tube). LPA Colvin reviewed staff files and observed that facility staff (S1 & S2) were not trained in care of bedridden residents or in providing care for G-Tubes. Deficiencies cited. Care of Bedridden Residents - LPA Colvin observed that the facility does not have fire clearance for bedridden residents, yet R1 was admitted and retained at the facility while bedridden for almost 1 year. Licensee informed LPA Colvin that R1 was on Hospice, which permits them to retain R1. LPA Colvin informed Licensee that Title 22 Regulation 87633(l) states that while the facility may retain a bedridden person on Hospice, they must still meet all the requirements of regulation section 87606. The facility has not met the requirements of 87606 as observed in this report. Deficiency cited. A violation of a facility's fire clearance results in an immediate $500 civil penalty, which will be issued at the end of the exit interview. Additionally, the facility does not have a Plan of Operation on file which includes care of bedridden residents. Deficiency cited. Hospice Records - LPA Colvin observed that the facility did not have any documentation relating to the Hospice care of R1. S1 stated that the family removed the hospice file without their permission. LPA Colvin noted that there should be a copy of the Care Plan in R1's file, which there was not. Deficiency cited. Unscrupulous Training Certificates - During LPA Colvin's review of staff files, LPA Colvin observed that the CPR certifications for all staff were expired. LPA Colvin inquired about current certification for staff, which S1 was able to provide to LPA Colvin after bringing out a separate large envelope. At this time, LPA Colvin observed several stacks of training certificates which looked identical from those found in staff files, though these certificates were blank where the staff name would be listed. LPA Colvin looked through these certificates and observed that they were identical to those in staff files, right down to listing all of the same training, same date, and same instructor. LPA Colvin questioned Administrator/Licensee Verly Frias regarding the certificates, and showed him the ones in staff files. Administrator/Licensee Verly Frias denied knowledge of these and could not account for who's signature the trainer on the certificates was, nor did he have their contact information. LPA Colvin reminded Verly that he is both the Licensee and Administrator for the facility, so he should have knowledge regarding staff training records. No explanation was provided during LPA Colvin's inspection regarding these blank records. Due to deficiencies cited today as well as concern with blank staff records, LPA Colvin invited Administrator/Licensee Verly Frias to an Informal Meeting via Zoom to discuss facility's plan for compliance. Informal Meeting will take place Tuesday, August 31, 2021 at 2:00pm. Due to observations made by LPA Colvn, the facility was cited deficiencies and civil penalties in the amount of $500 were issued. LPA Colvin conducted an exit interview with Administrator/Licensee Verly Frias, where a copy of this report, LIC809Ds, LIC421IM, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 27, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Aug 31, 2021

Fire Clearance: (a) All facilities shall maintain a fire clearance...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance... (2) Bedridden persons. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed R1 , who is bedridden, lived at the facility for almost 1 year while the facility failed to obtain fire clearance for bedridden residents. This was an immediate safety risk for R1.the state’s words, verbatim · CDSS document, Aug 27, 2021

Plan of correction: Licensee agrees to either apply for bedridden fire clearance through CCL or provide Statement of Understanding that they will not accept/retain any bedridden residents, despite Hospice status. Submission of request for clearance or Statement due by Plan of Correction date of 8/31/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87606(f)(1) · Plan of correction due date: Aug 31, 2021

Care of Bedridden Residents: (f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. This requitement was not met by: Based on record review, the Licensee did not comply with the above regulation. The facility retained R1, who is bedridden, for almost one year without having a Plan of Operation regarding care of bedridden residents. This was a potential health and safety risk for R1.the state’s words, verbatim · CDSS document, Aug 27, 2021

Plan of correction: Licensee agrees to submit updated Plan of Operation in regards to Care of Bedridden Residents, should Licensee choose to apply for a fire clearance and request to accept these persons. If the Licensee does not wish to apply for the Fire Clearance, Licensee to submit Statement of Understanding that they will not accept/retain any bedridden residents. Submission of request for clearance or Statement due by Plan of Correction date of 8/31/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87606(f)(3) · Plan of correction due date: Aug 31, 2021

Care of Bedridden Residents: (f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least 2 staff members (S1 & S2). LPA Colvin observed that S1 & S2 do not have required training on care of bedridden residents, yet provided care to R1, who was bedridden. This was an immediate health risk for R1.the state’s words, verbatim · CDSS document, Aug 27, 2021

Plan of correction: Licensee agrees to have all staff trained on care for bedridden residents, should Licensee plan on submitting request for bedridden fire clearance from CCL. Should Licensee choose not to file request, Licensee to provide LPA Colvin with Statement of Understanding that they will not accept/retain any bedridden. Submission of staff training or Statement due by Plan of Correction date of 8/31/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87633(f) · Plan of correction due date: Aug 31, 2021

Hospice Care of Terminally Ill Residents: (f) The licensee shall maintain a record of all hospice-related training provided to the licensee or facility personnel for a period of three years. This record shall be available for review by the Department. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least 2 staff members (S1 & S2). LPA Colvin observed that there was no record of staff training for care of R1's G-Tube, for which R1 was receiving Hospice care for. This was an immediate health risk to R1.the state’s words, verbatim · CDSS document, Aug 27, 2021

Plan of correction: Licensee to provide LPA Colvin with a Statement of Understanding that facility to maintain all records of hospice training for 3 years. Statement of Understanding to be provided to LPA Colvin by the Plan of Correction date of 8/31/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(h)(4) · Plan of correction due date: Aug 31, 2021

Hospice Care of Terminally Ill Residents: (h) For each terminally ill resident receiving hospice services...the licensee shall maintain the following in the resident’s record: (4) A copy of the resident’s current hospice care plan... This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least one resident (R1). LPA Colvin observed that there was no Hospice Care Plan on file for R1 in the facility's records. This is a potential health risk for R1.the state’s words, verbatim · CDSS document, Aug 27, 2021

Plan of correction: Licensee agrees to ensure that the facility has a copy of all care plans for all residents receiving hospice or home health services in the facility's resident record. Licensee to conduct audit of current residents and ensure this requirement is met. Licensee to self-certify to LPA Colvin once audit is complete. Self-certification due to LPA Colvin by Plan of Correction date of 8/31/21.