Rising Sun Home

Type of visit: Required - 1 Year

On 11/8/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Licensee, Conchita Diata, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (2) resident present. The facility is a one story home with attached garage. No firearms or pools are present at the facility. The home has (6) bedrooms and (5) bathrooms. The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: The LPA observed hand washing stations with hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train staff on infection control guidelines. Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide were operational, and the hot water temperature was recorded at 118F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Record Review and Resident/Staff Files: LPA reviewed staff files and training. Staff have criminal clearance and have updated training along with CPR/First Aid Certification. The administrator has proof of a processing administrator certificate with the department. Resident files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in kitchen pantry. LPA reviewed resident medications, all of which were accounted for. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last fire drill was conducted in 2021, a technical advisory note was documented and licensee agreed to hold fire drill by the end of the business day. LPA observed emergency exits and emergency supplies. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was reviewed and provided to Licensee, Conchita Diata.the state’s words, verbatim · CDSS document, Nov 8, 2023

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: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Crystal Colvin conducted an unannounced visit to the facility for a case management visit, for the purpose of approving the facility's request for ambulatory status change. LPA met with Licensee/Administrator Conchita Diata, who assisted LPA Colvin with conducting a tour of the facility. Per the LIC200, the Licensee submitted a request for allowance for one (1) bedridden resident. Facility is already approved for six (6) non-ambulatory residents. A representative from the Fire Marshal conducted a fire safety inspection on 12/2/21 and approved for the change in ambulatory status. During today’s visit, the LPA Colvin toured the facility and inspected the master bedroom, which was approved by the Fire Marshall for accommodating on non-ambulatory and one bedridden resident. LPA Colvin observed that bedroom #4 (which has been approved for bedridden by the Fire Marshal) is in good repair and had the required furniture and is complete with a ramp an exit door inside the bedroom leading to directly outside of the facility. Licensee has also provided LPA Colvin with a Bedridden Care Plan which LPA Colvin will be adding to the facility's file. Facility has been approved for 1 bedridden resident as of today's date. LPA advised that she update the facility license and provide the Licensee with a new copy to reflect the change in ambulatory status next week. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Licensee/Administrator Conchita Diata.the state’s words, verbatim · CDSS document, Dec 14, 2021

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPAs Colvin and Mixon met with Licensee/Administrator Conchita Diata 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 Licensee/Administrator Conchita Diata, who LPA Colvin found to be successfully incorporating several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels. 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 LPA Colvin observed to not be sufficient for a 30-day supply. Licensee/Administrator Conchita Diata informed LPA Colvin that they have been unable to purchase supplies online, which is why they do not have any N95 msks, isolation gowns, or face shields. LPA Colvin will be issuing a TA Advisory Note instead of a deficiency as it is recommended that the facility maintain a 30-day supply of PPE at all times. LPA Colvin will additionally coordinate to have supplies brought to the facility ASAP to ensure they have everything needed on hand in case of a COVID-19 case. Upon entry of the facility, LPAs observed that facility staff did not take LPAs temperature or have LPAs sign-in on a sign-in sheet. LPA Colvin inquired as to if the facility has the Hospcie Nurses sign in and have their temperature taken by staff, and the Licensee stated that no they do not. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note instead of a deficiency (for lack of screening & sign in)as it is only a recommendation by the Department at this time for facilities to screen all visitors prior to admitting to facility, as well as utilizing a sing-in sheet. The Licensee was advised to begin incorporating these recommendations as they may become regulations in the future, for which the facility may be cited deficiencies for. LPAs additionally inquired with the Licensee as to if the front door (which LPAs entered through) is the only entry way being used at this time, as recommended for infection control. The Licensee stated that Hospice goes through another door by the garage, as it is closer to the resident's (R1) room, and they do not need to walk throughout the entire facility. A TA Advisory Note will be cited due to Community Care Licensing (CCL) recommendation for a single entry and exit point to be used. LPA Colvin went over the various recommended training for facility staff with Licensee/Administrator Conchita Diata 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 Licensee/Administrator Conchita Diata informed LPA Colvin that at this time staff have not been fit tested. A TA Advisory Note will be cited due to CCL recommendation for all staff to be fit tested for N95 masks. 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 provided Licensee/Administrator Conchita Diata with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. LPA Colvin inquired about if the facility is still conducting COVID-19 surveillance testing of their unvaccinated staff members. Licensee/Administrator Conchita Diata informed LPA Colvin that all staff are vaccinated, so continued testing is not required. In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Licensee/Administrator Conchita Diata confirmed that staff are continuing to monitor residents’ symptoms, and that if someone in the facility tests positive for COVID-19 that all staff and residents will be tested at least twice to confirm no additional positive cases. Additional Items: During LPAs inspection of the facility, LPAs observed one resident (R1) at the facility, whom the Licensee stated is "bed-bound". LPA Colvin inquired as to if R1 was "bed-bound" or bedridden, specifically, if staff needed to turn R1. Licensee confirmed that staff are required to turn R1. LPA Colvin observed that the facility does not have approved fire clearance for any bedridden residents, and is only approved for non-ambulatory. LPA Colvin further confirmed R1's bedridden status through review of R1's hospice records, which state that R1 is bed-bound (only option available other than independent or non-ambulatory) and that R1 requires "full assist" with all Activities of Daily Living (ADLs). The Licensee stated that a previous LPA informed her that so long as a resident is on Hospice they do not require a bedridden waiver. LPA Colvin informed the Licensee that Health and Safety Code 1569.73(h) states that even if a resident is on Hospice, the facility is still required to have an approved Fire Clearance from the Fire Department. Deficiency cited. A violation of a facility's fire clearance comes with an immediate civil penalty in the amount of $500 due to the severity of the violation. A civil penalty for $500 is being assessed during today's inspection. Additionally, while looking through R1's records, LPA Colvin observed that R1's Pre-Appraisal and Functional Capabilities Assessment have not been updated since 2019, at which point R1's needs were very different from what they are today, as observed by it noting R1 is non-ambulatory and not on Hospice. Facilities are required to update these documents as residents' needs change. Deficiency cited. An exit interview was conducted with Licensee/Administrator Conchita Diata and a copy of this report, Licensing Application (LIC200) to apply for an ambulatory status change, LIC809D, LIC421IM, appeal rights, and LIC9102 TA Advisory Notes were provided. Note: The Licensee refused to sign the LIC421IM due to disagreeing with the civil penalty. Noted on the form that Licensee refused to sign.the state’s words, verbatim · CDSS document, Nov 18, 2021

The state marks this report as 9 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.