Montage Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that four (4) clients live at this facility. There was two (2) staff members present. The House Manager, Vanessa Franco conducted and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Four (4) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Cyndy Zaech, Administrator’s certificate expiration date is 09/11/2024. (Continued on LIC809C) (Continuation from LIC809) Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 77 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 110.0 degrees F. Laundry is done in the designated laundry room. There is a locked cabinet for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is one (1) secured fireplace at this facility. There is one (1) secured pool at the facility. There is one (1) gate that has a self-latching lock on the northwest side of the house. The facility had their last emergency fire drill on 07/15/23. LPA observed emergency supplies and first aid with the required components. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. (Continued on LIC809C) (Continuation from LIC809) Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed if they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed twelve (12) smoke detectors and two (2) carbon monoxide detectors. There was one (1) fire extinguisher on site, it was serviced and charged on 06/08/2023. Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the House Manager, Vanessa Franco.the state’s words, verbatim · CDSS document, Sep 20, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPA was greeted by House Manager Vanessa Franco and explained the purpose of today's visit. There were 5 residents inside the facility at the time of visit. During today’s visit, LPA toured the facility and made observations pertaining to the facility’s infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, and sufficient cleaning and disinfecting provisions. The facility was noted to have a 30 days supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in 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 clients, 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 clients 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 illness. An exit interview was conducted, and a copy of this report was discussed with and provided to House Manager Vanessa Franco.the state’s words, verbatim · CDSS document, Sep 2, 2022

Allegation investigated: Resident not administered medication as prescribed.

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to investigate the above allegation. LPA conducted an inspection of the facility, and interviewed staff, and a resident. Review of documents and interviews with staff and Licensee revealed resident 1 (R1) has been receiving medication as ordered by Physician. During an inspection of the facility on 8/19/22, LPA did not observe any over the counter medications that were associated to R1. Staff and Licensee also stated that over the counter medications were not being provided. Continued on LIC9099-C. Unsubstantiated LPA conducted interviews, and received documents in relation to this complaint which both revealed that medication is being administered as ordered by the Physician. Thus this complaint is UNSUBSTANTIATED. 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 and a copy of this report was discussed with and provided along with a copy of the LIC9099-C, and LIC811.the state’s words, verbatim · CDSS document, Aug 19, 2022 · control 18-AS-20220811142049

Allegation investigated: Staff handled resident in a rough manner. Staff caused injury to resident. Staff does not treat resident with dignity and respect.

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to investigate the above allegations. LPA identified himself and met with House Manager Vanessa Franco who accompanied LPA on a tour of the facility. Regarding the allegation, "Staff handled resident in a rough manner". LPA found that through interviews with S1, S2, and R1, LPA did not find that staff handled resident in a rough manner during an incident which occurred in June, 2022. Regarding the allegation, "Staff caused injury to resident." During the aforementioned incident in June, 2022, LPA found that while S2 was helping R1 get dressed for the day, during the process, an earring was dislodged from R1's ear. The manner in how it was dislodged was not determined by this LPA. Continued on LIC9099-C. Unsubstantiated Regarding the allegation, "Staff does not treat resident with dignity and respect." Through interviews with residents, and witnesses, LPA found that R1 is treated with dignity and respect. Due to interviews, and information obtained, LPA was not able to corroborate the allegations; therefore, the complaint is found to be UNSUBSTANTIATED. 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 with and provided to Vanessa Franco.the state’s words, verbatim · CDSS document, Aug 8, 2022 · control 18-AS-20220805105246

Type of visit: Case Management - Health Checks

On the above date Licensing Program Analysts (LPA's) Crystal Colvin and Venus Mixson made an unannounced case management visit and were greeted and granted entry by Manager Vanessa Franco. LPA Colvin inquired about the residents at the facility and confirmed that their care has not been disrupted since the passing of Roland Zaech. LPA Colvin found the facility to be in good condition, and the residents gathered in the living room watching television. LPA Colvin requested for facility manager to have the licensee submit the following documents to Community Care Licensing: - Break down of the shares of the corporation. - List of active officers in the corporation. - LIC 200 Facility scheduled roster for staff. - LIC 308 - LIC 309 - Updated lease agreement. - Death Certificate or other proof of passing Roland Zaech. LPA's informed Manager Vanessa Franco that these documents would need to be submitted by 4/20/2022.If required documents are not received by this date, an office meeting may be required to discuss facility compliance. No health or safety concerns observed at this time. Exit interview was conducted and this report was left with Vanessa Franco.the state’s words, verbatim · CDSS document, Apr 6, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting a Case Management Inspection to follow up on the recent passing of Co-Licensee Roland Zaech. LPA Colvin met with Facility Manager Vanessa Franco and advised her of the purpose of today's visit. LPA Colvin inquired about the residents at the facility and confirmed that their care has not been disrupted since the passing of Roland Zaech. LPA Colvin found the facility to be in good condition, and the residents gathered in the living room watching television. No health or safety concerns observed at this time. LPA Colvin advised Facility Manager Vanessa to have surviving Licensee Cyndy Zaech to contact the Central Application Branch (CAB) of Community Care Licensing (CCL) and to inquire about what forms need to be updated. CAB can be reach at 833-827-6084. Additionally, while LPA Colvin was at the facility, LPA Colvin informed Facility Manager Vanessa that the facility has past due fees in the amount of $742.00 for last year's annual licensing fee and subsequent late fee. LPA Colvin will be issuing a Technical Violation today for the past due fees instead of a deficiency due to the recent passing of the Licensee. LPA Colvin also consulted with Facility Manager Vanessa regarding the "No Visitors" sign on the front door. Despite the sign, there is substantial evidence of the facility allowing visitors, as there is a sign in sheet at the front door, which has a long list of entries. LPA Colvin assured Facility Manager that she is confident that the facility is in fact allowing visitors and not violating residents' rights, but recommended that they remove the sign from the door to prevent false impressions. LPA Colvin informed Vanessa that if they so choose, they can instead replace the sign with one that states "No entry without mask". LPA Colvin conducted an exit interview with Facility Manager Vanessa Franco, and a copy of this report and LIC9102-TV Technical Violation was provided.the state’s words, verbatim · CDSS document, Mar 18, 2022