Peace and Joy RCFE

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an required 1 year visit. LPA was granted entrance by Administrator, Favie Jimeno. The facility is a four (4) bedroom two (2) bathroom one story home. LPA conducted staff and resident interviews. During the tour the following was observed: Required accommodations in resident bedrooms and bathrooms. Fixtures and furniture for an operational facility are present and in good repair. Handrails are securely fastened, grounds are free from hazards. All bedrooms are adequately furnished and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible to dementia residents. Hot water was tested at 120 degrees. Kitchen/Food Service: LPA observed entire kitchen, food is stored properly and dishes are clean. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be functional and clean. Care & Supervision: Facility has sufficient care staff. Administration: Emergency exiting plans, telephone numbers and Ombudsman information are posted. Fire drills are conducted quarterly. Record Review and Resident/Staff Files: Current staff has Criminal Clearance and CPR/First Aid certification as well current training. Resident records were reviewed and contained required documents. Medication Review: LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders. No cited deficiencies per Title 22, Division 6 of the California Code of Regulations cited at this time. Exit interview conducted and a copy provided to Administrator Favie R. Jimeno.the state’s words, verbatim · CDSS document, Aug 18, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 10:30 AM, signed in and utilized hand sanitizer. The LPA met with Administrator, Favie Jimeno, and informed her of the purpose of her visit. There is currently one COVID-19 positive resident in care at the facility. During today's visit, the LPA toured the facility and made observations pertaining to the facility's infection control measures. The LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and 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 infection control. The facility has a plan in place (Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report) which follows 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 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, Chapter 8 of the California Code of Regulations. An exit interview to review this report was conducted with Jimeno and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 24, 2022

Allegation investigated: #1. Staff is failing to administer resident's medication as prescribed.

Licensing Program Analyst (LPA) Venus Mixson and Licensing Program Manager (LPM) Joel Esquivel made an unannounced visit to the facility and met with administrator Favie Jimeno, to investigate the above allegation. Regarding the above allegation LPA did an investigation which consisted of touring the facility, interviewing the staff, reviewed documentation and medications. Substantiated Based on the information reviewed LPA found several discrepancies with the dispensing of medications. LPA found several medications that were not being dispensed as per physicians instructions; as such the allegation; Staff is failing to administer resident's medication as prescribed is found to be Substantiated. A substantiated finding means the totality of the evidence supports the allegation. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC 9099D. Exit interview conducted and copy of appeal rights and this report was provided to administrator Favie Jimeno. Based on the information reviewed LPA found evidence that showed that the resident #1 (R1) handled own funds. Facility staff did not handle R1s cash in any way and was self sufficient as per documentation. As such the allegation, Staff are mishandling resident personal funds, was deemed as UNFOUNDED. Regarding allegation #3. Staff fail to ensure resident is properly fed while in care. LPA found that R1 had no diet restrictions. Facility provides food and snacks to all other resident. However, R1 did not approve of this food and as such would leave the facility to purchase his own food selection via public transportation. Therefore the allegation, Staff fail to ensure resident is properly fed while in care is deemed as Unfounded. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with administrator Favie Jimeno and a copy of this report along with LIC 811 was provided.the state’s words, verbatim · CDSS document, Dec 23, 2021 · control 18-AS-20200611094154

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 31, 2021

If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. This was not met because the facility could not prove that the medication was dispensed as per physicans instructions.the state’s words, verbatim · CDSS document, Dec 23, 2021

Plan of correction: The licensee will provide training to all staff regarding proper dispensing of medication by 12/31/2021.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Venus Mixson and Licensing Program Manager (LPM) Joel Esquivel made an unannounced visit to the above facility to conduct a complaint investigation for complaint log#18-AS-20200611094154. LPA met with the acting administrator Favie Jimeno. The following deficiencies were found during this visit. -Missing smoke alarm - Auditory door alarm not turned on or working -Unlocked medications -Possible room added in garage alterations - Crushing medication device and pill cutting device -Broken floor tiles -Hoyer lift in service -Expired Administrator certification Please See 809-D for deficiencies of the items listed. An exit interview was conducted and a copy of this report and appeal rights were provided during this visit.the state’s words, verbatim · CDSS document, Dec 23, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Dec 27, 2021

87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic This was not met because the smoke alarm was missing from the a residents room #2.the state’s words, verbatim · CDSS document, Dec 23, 2021

Plan of correction: Administrator will purchase and replace missing smoke alarm by 12/27/2021. Licensee will submit a photograph as proof of compliance by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(j) · Plan of correction due date: Dec 23, 2021

Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This was not met by; the facility failed to use the auditory alarm as designed. All auditory alarms had been turned off and doors were left ajar during visit.the state’s words, verbatim · CDSS document, Dec 23, 2021

Plan of correction: The administrator will provide training on the proper care of persons with Dementia.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(H)(2) · Plan of correction due date: Dec 24, 2021

Incidental Medical and Dental Care.The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This was not met because medication were left unatended/ not locked on main floor accessible to dementia residents.the state’s words, verbatim · CDSS document, Dec 23, 2021

Plan of correction: The administrator will be sure to have all medications secured inacessible to residents at all time.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(6)(D) · Plan of correction due date: Dec 31, 2021

Incidental Medical & Dental Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: The LPA observed a pill crusher inservices without perscription or authorization for use.the state’s words, verbatim · CDSS document, Dec 23, 2021

Plan of correction: The facility will remove any pill crusher or cutter unless there is a physician authorization or precription.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Dec 31, 2021

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met because, LPA observed several tiles that were broken near the kitchen.the state’s words, verbatim · CDSS document, Dec 23, 2021

Plan of correction: The administrator will repair or replace broken tiles through out the facility by 12/31/2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR87406(a) · Plan of correction due date: Dec 31, 2021

Administrator - Qualifications and Duties.All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This was not because LPA observed that the administrators certificate was expired during visit.the state’s words, verbatim · CDSS document, Dec 23, 2021

Plan of correction: The administrator will submit proof of correction by due date 12/31/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Dec 31, 2021

Alterations to Existing Building or New Facilities. Prior to construction or alterations, all facilities shall obtain a building permit. LPA observed additional rooms in the garage being used as living quarters.the state’s words, verbatim · CDSS document, Dec 23, 2021

Plan of correction: Licensee will submit proof that rooms mentioned in garage were permitted by city code by due date 12/31/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(D)(1) · Plan of correction due date: Dec 31, 2021

Administrator - Qualifications and Duties The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. The LPA observed that the facility was using a hoyer lift without proper documented training or without proper instuction from a licensed proessional.the state’s words, verbatim · CDSS document, Dec 23, 2021

Plan of correction: The licensee will remove or seek training for the equipment used for the residnets needs by due date. 12/31/2021

Allegation investigated: Facility staff are not following resident's medical orders.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the above allegation. LPA George met with Administrator Favieruth Jimeno and explained the purpose for the visit and elements of the allegation. Below is a summary of the investigation. LPA reviewed documentation such as Resident #1 (R1) physician's report, care plan, nurse reports, individual resident logs, and resident appraisal. Based on the nurses’ notes reviewed, which revealed that R1 was actively going outside to speak with the neighbor, went to get food from a fast food restaurant, watching TV in the living room , going to pick up their medication from the pharmacy, as well as going to the store to buy snacks. Per R1's care plan, R1 was to get out of bed at least every other day. There were days where R1 was noted to be sick and not feeling well. There were no reports to support that on those days R1 gotten up out of the bed. Per the physician’s report dated 10/5/17, R1 is diagnosed with major depressive disorder, and Guillian Barre Syndrome. Unsubstantiated Per Administrator Cecile Jimeno, R1 would have times when they would become depressed and express feelings of hopelessness due to their physical limitations. LPA was unable to successfully interview R1 due to not getting a response or being at the facility when attempts were made. LPA made one final attempt and was informed that R1 was discharged from the facility on 12/29/20 and passed away in January 2021. Based on interview, and record review LPA was unable to corroborate the allegation of facility staff are not following resident medical orders. The allegation is UNSUBSTANTIATED. A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided to Administrator Favieruth Jimeno.the state’s words, verbatim · CDSS document, Sep 15, 2021 · control 18-AS-20200831091550

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced annual inspection with an emphasis of infection control. LPA Gardner met with Administrator Favieruth Jimeno and toured the facility. LPA Gardner inspected the facility and the following was observed: The home is one story, four bedroom, two bath home with a living room, dining room, and kitchen. The smoke/carbon monoxide detectors were tested and observed to be operational. Towels, linens were observed and appeared to be sufficient for residents in use. The residents rooms were furnished with bed, dresser, chair and lighting for residents comfort. The residents medication are stored in a locked cabinet in the kitchen. The knives are kept with the cleaners under the kitchen sink in a locked cabinet. LPA Gardner observed the kitchen to be supplied with adequate plates, cups, dishes and silverware, as well as pots, pans and serving bowls for residents use. The food supply was inspected and met the minimum requirement of 7 days non-perishable and 3 days perishable foods. The backyard is fully fenced and has chairs and shade for residents use. During the inspection LPA Gardner asked Ms. Jimeno about the residents. Ms. Jimeno stated that the facility is approved for 6 residents, of which 2 can be on hospice. Ms. Jimeno indicated that she currently has 3 residents on hospice. A records review indicated that the 3rd hospice resident, R1, was admitted on 5/31/21, and began receiving hospice care on 8/10/21. During the inspection LPA Gardner reviewed infection control practices and procedures with Ms. Jimeno. An exit interview was conducted and a copy of this report, along with LIC 809D and appeal rights were reviewed with and provided to Ms. Jimeno.the state’s words, verbatim · CDSS document, Aug 31, 2021

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Aug 31, 2021

CCR 87632(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. This requirement was not met as evidenced by: Based on interview, and record interview, licensee failed to ensure an approved hospice waiver was in place upon retaining a resident on hospice. This poses an immediate health and safety to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2021