Affinity Senior Living 1

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with the Caregiver, Gloria Antonio. LPA was informed that ten (10) residents currently reside at this facility, with a capacity of ten (10). There were two (2) staff on duty during the time of the visit. LPA toured the facility and observed all facility utilities to be on and operating without issues. There is no immediate concern for residents in care. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Caregiver, Gloria Antonio and a copy of this report is left with the her as evidence by her signature.the state’s words, verbatim · CDSS document, Oct 10, 2023

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with the caregiver, Gloria Antonio. LPA was informed that nine (9) residents currently reside at this facility, with a capacity of ten (10). There were two (2) staff on duty during the time of the visit. LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care. LPA observed R1's medication at the facility. LPA did not observe R1's files at the facility. LPA spoke to the Administrator, Anson Cayabyab on the phone regarding R1’s files; (physician report, written record of care, and emergency information). The Administrator stated that he will have the files at the facility where R1 resides by August 23, 2023. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Caregiver, Gloria Antonio and a copy of this report is left with the her as evidence by her signature.the state’s words, verbatim · CDSS document, Aug 22, 2023

Type of visit: Office

On April 14, 2023, Licensing Program Analyst (LPA) Jesse Gardner and Licensing Program Manager (LPM) Joel Esquivel conducted an announced informal meeting also in attendance was the Administrator Analisa Cayabyab. Items discussed during this informal meeting were: Recent complaint concerns Resident does not have proper storage space for personal belongings Facility lacks night supervision for residents with dementia Facility staff use restraint on resident at night to prevent them from wandering Licensee has three residents sharing room During this meeting it was stated that the licensee, Rita Wong could not attend due to personal injury. Administrator Analisa Cayabyab stated that she would provide a copy of the report to Ms. Wong. Ms. Wong will provide response to CCL by April 17, 2023, regarding the issues discussed.the state’s words, verbatim · CDSS document, Apr 14, 2023

Allegation investigated: Resident does not have proper storage space for personal belongings Facility lacks night supervision for residents with dementia Facility staff tie a resident to their chair at night to prevent them from wandering Licensee has three residents sharing room

Licensing Program Analyst (LPA) Jesse Gardner, conducted an unannounced visit to the facility to initiate the investigation into the above allegations. LPA was greeted by staff, Gloria Antonio, and informed her of the purpose of the visit. Administrator Analisa Cayabyab, arrived while conducting a tour of the facility. It was alleged that Resident 1 (R1) has their personal belongings in bags on their bedroom floor. Through interviews with staff, and observation, LPA found that R1 has resided at the facility for approximatey 3 years, and has not been afforded a chest of drawers for their belongings. LPA found that this allegation was SUBSTANTIATED. Substantiated It was further alleged that staff are in a room at night, and if residents need something they have to knock on a staff door for assistance. LPA found that, through interviews with residents and staff that night shift staff sleep during the night, and do not remain awake to assist and direct residents. The facility was found to have dementia residents in care via R2's Physician's Report, and that comes with a requirement that there is awake staff. Thus, this allegation was SUBSTANTIATED. It was then alleged that staff tie a resident to a chair at night to prevent them from wandering into other resident's rooms. Through interviews with staff, LPA found that R2 is restrained to a rocking chair in the living room with a sheet to prevent R2 from walking throughout the facility at night. Staff were found to sleep after R2 is asleep in their chair. Thus, this allegation was SUBSTANTIATED. It was also alleged that there are three residents sharing the same room. Upon inspection, LPA observed three residents, Resident 4 (R4), Resident 5, (R5), and Resident 6 (R6) sharing the same bedroom. Thus, this allegation was SUBSTANTIATED. The facility was issued 4 citations per Title 22. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC9099, LIC9099-C, LIC9099-D, LIC811, and Appeal Rights.the state’s words, verbatim · CDSS document, Mar 9, 2023 · control 18-AS-20230301094340

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(4)(a) · Plan of correction due date: Mar 10, 2023

Care of Persons with Dementia (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement was not being met as evidenced by: Based on interviews with staff, LPA found that staff sleep during the night shift. Administrator is aware of this, and found that as long as nothing is going on, it was permitted. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 9, 2023

Plan of correction: Licensee agrees to develop a plan how they are going to address staff sleeping at night time, and submit to LPA by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 10, 2023

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 personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not being met as evidenced by: Based on staff interviews, LPA found that R2 was secured to a rocking chair at night to prevent them from walking throughout the facility. This presents an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 9, 2023

Plan of correction: Licensee agrees to submit in-service training regarding the personal rights of residents in care, and submit to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(2)(D) · Plan of correction due date: Mar 23, 2023

Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (D) Not more than two residents shall sleep in a bedroom. This requirement was not being met as evidenced by: Based on observation, and interview, LPA found three residents residing in the same room. This presents a potential health and safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 9, 2023

Plan of correction: Licensee stated that they will relocate a resident from Room #6 to adhere to the regulation and submit proof of such by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(B) · Plan of correction due date: Mar 16, 2023

Personal Accommodations and Services:(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This was not being met as evidenced by: Based on LPA observation, and interview with staff, R1 has clothes in plastic bags on their floor. LPA did not observe a chest that was capable of storing all of R1's belongings.the state’s words, verbatim · CDSS document, Mar 9, 2023

Plan of correction: Licensee stated they will provide a chest of drawers to the resident and provide proof of such to LPA by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit on 1/13/2023 at 11:15 a.m. in order to conduct an annual visit with a focus on infection control. LPA met with Administrator, ANALISA CAYABYAB, who was informed of the purpose of the visit. At the time of the visit there were (4) staff and (10) residents present. LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point for facility visits. LPA observed COVID-19 postings at the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for residents and staff. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, soap, running water and paper towels. The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. The staff have also been FIT tested for an N95 respiratory and will be due for their annual test. LPA was informed that the facility is no longer taking temperatures for staff and visits. LPA will document a technical advisory note, that administrator was advised to conduct temperature checks on a regular basis for visitors and staff at the beginning of their shift LPA asked for a copy of the resident roster and administrator was unable to locate it during the time of the visit. LPA advised administrator to have this readily available for licensing review. LPA was able to review list of staff names on facility emergency disaster plan. This will be documented on a technical advisory note. The administrator will email a copy of the staff roster to the LPA by today close of business. During the time of the visit, LPA observed staff were not wearing their face masks. LPA advised administrator of the current guidance for all staff to wear face masks inside of the facility. Staff put on their face mask immediately after LPA advised them to. This will be documented on a technical advisory note for staff to continue this practice. LPA observed the facility had a pool in the backyard, and observed the locked gate securing the pool. No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided to Administrator, ANALISA CAYABYAB.the state’s words, verbatim · CDSS document, Jan 13, 2023

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: 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 Analisa Cayabyab 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 Analisa Cayabyab, 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 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 be sufficient for a 30-day supply. LPA Colvin went over the various recommended training for facility staff with Administrator Analisa Cayabyab 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 Analisa Cayabyab 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 Administrator 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 screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Analisa Cayabyab stated that residents are not being screened daily, as they do not leave the facility and there are no visitors coming inside unless they are vaccinated or have a negative COVID test. LPA Colvin will be issuing a Technical Assistance Advisory Note due to facility not following Community Care Licensing (CCL) recommendations for daily screening of COVID-19 symptoms of residents. LPA Colvin observed a sign-in sheet at the front door of the facility, which LPA Colvin used to sign-in at the beginning of today's inspection. LPA Colvin additionally observed that the sign-in sheet did not include COVID-19 symptom screening questions, or indication that staff took the temperature of the visitor. Likewise, LPA Colvin's temperature was not taken before entering the facility, or being permitted to move about the facility. LPA Colvin will be issuing another Technical Assistance Advisory Note due to staff not screening visitors who enter the facility for COVID-19 symptoms, such as by taking their temperature. LPA Colvin was shown a copy of the facility's Mitigation Plan during today's inspection, but LPA Colvin was unable to locate one in CCL's files. LPA Colvin requested for the Administrator to fax a copy of the Mitigation Plan to LPA Colvin later today. Similarly, the Administrator inquired about the status of a Hospice Waiver Increase that the facility had requested previously with another LPA, which they had been told was approved. LPA Colvin checked the database and could only locate an approval for an increase for 4 Hospice residents, but the Administrator stated that there had been another request to increase the approval to 6. LPA Colvin requested for the Administrator to send LPA Colvin the request as there is no record of the approval on file, and LPA Colvin wants to ensure that the request is processed for the facility. An exit interview was conducted with Administrator Analisa Cayabyab and a copy of this report and LIC9102 TA Advisory Notes were provided.the state’s words, verbatim · CDSS document, Jan 6, 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.

Allegation investigated: Staff do not prevent a resident from causing harm to other residents while in care

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegation. The LPA was greeted by staff, Gloria Antonio, and informed her of the purpose of the visit. Administrator, Analisa Cayabyab, was contacted via telephone and informed of the purpose of the visit. Pertaining to the allegation, "Staff do not prevent resident from causing harm to other residents in care," it was alleged Resident Two (R2) is casing harm to Resident One (R1) by harassing them. R1 was interviewed and reported R2 harasses them by making threats to come into their bedroom without permission, and does successfully make entry. R1 reported R2 has not hurt them or other residents in care. R2 was interviewed and could not provide a statement on the allegation. Administrator Cayabyab was interviewed and reported R2 is new to the facility and is orienting themself to the home. She reported R2 has gone into R1s bedroom, though is looking for the bathroom. Staff interviews were conducted; it was reported R2 has gone into R1's bedroom, though is quickly redirected. Staff reported R2 does not make threats to come into R1's bedroom without Unsubstantiated permission. Resident interview was conducted; it was reported no resident comes into their bedroom without permission or threatens to do so. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with Administrator Cayabyab and a copy was provided via email.the state’s words, verbatim · CDSS document, Jul 20, 2021 · control 18-AS-20210712100443