Petunia Royale Assisted Living

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 five (5) clients live at this facility. There were two (2) staff members present. The Caregiver, Maria Siasat conducted the facility tour. There is an Infection Control Plan on file. Client Records-Incident Reports/Clients Rights-Information/Dental- LPA reviewed client records. Five (5) 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/and Staffing- 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. Jason M Mabbayad Administrator’s certificate expiration date is 12/28/2024. (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 76 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 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 two (2) secured fireplace at this facility. There is not a pool at the facility. There are two (2) gates that have a self-latching lock on the northwest and northeast side of the house. The facility performed their last fire and emergency drills on April 5th, 2023. Medications- 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. (Continued on LIC809C) (Continuation from LIC809) LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed seven (7) dual fire alarms and carbon monoxide detectors. The caregiver tested the smoke alarms and carbon monoxide alarms on site. There is one (1) fire extinguisher on site, bought on 03/24/2023. 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 Caregiver, Maria Siasat.the state’s words, verbatim · CDSS document, Aug 14, 2023

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 caregiver Vincent Cabauatan 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 caregiver Vincent Cabauatan, who LPA Colvin found to be successfully incorporating the several aspects of the infection control, despite not having a Mitigation Plan on file. LPA Colvin inquired about if there was a copy at the facility for LPA Colvin to review (as there is no evidence that one has been submitted to Licensing) and the caregiver Vincent Cabauatan stated that there is not. LPA Colvin will be issuing a Technical Advisory Note for the facility not having a Mitigation Plan. LPA Colvin will not be issuing a deficiency as the Mitigation Plan request/requirement is outdated, and facilities are now being advised to submit an Infection Control Plan. 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). LPA Colvin observed the facility to not have an adequate supply of PPE, and caregiver Vincent Cabauatan was unaware of where additional PPE might be located. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note for the facility not having a 30-day supply of PPE. LPA Colvin went over the various recommended training for facility staff with caregiver Vincent Cabauatan 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 caregiver Vincent Cabauatan informed LPA Colvin that they have. LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. caregiver Vincent Cabauatan 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, as LPA Colvin was today. LPA Colvin additionally confirmed that all facility staff are vaccinated, so the facility is not required to continue with surveillance testing weekly, and caregiver Vincent Cabauatan confirmed that both new staff and new residents must present a negative COVID-19 test prior to start of employment or residence at the facility. Other: During LPA Colvin's inspection, LPA Colvin observed that Vincent Cabauatan and his wife Ingrid were both not on the facility's employee roster, or associated to the facility. LPA Colvin contacted two staff back at the Licensing Office to double and triple check, and both staff confirmed that while both Cabauatans have background clearance, neither is associated to any facility. LPA Colvin inquired with Vincent Cabauatan as to how long he and his wife have been working at the facility. Vincent Cabauatan claimed that today was his and his wife's first day, though they have worked here previously. LPA Colvin attempted to contact the Administrator to verify employment start date, but was unable to reach them. LPA Colvin will be citing a deficiency and issuing civil penalties in the amount of $100 per staff for one day working at the facility, for a total of $200. LPA Colvin will additionally be issuing a deficiency for not being able to access staff files. An exit interview was conducted with caregiver Vincent Cabauatan and a copy of this report, LIC809D, LIC421BG, appeal rights, and LIC9102 TA Advisory Notes were provided.the state’s words, verbatim · CDSS document, Aug 30, 2022

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Resident was inappropriately restrained while in care Facility does not have hot water

On 11/8/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannouced visit for the purpose of delivering the findings to the above allegations. LPA Henry met with Floreline Esteban, explained the purpose of the visit and was granted entry into the facility. The investigation, which consisted of interviews and document review, revealed the following: Resident was inappropriately restrained while in care : The hospice nurse of Resident 1 (R1) stated they visited R1 on 1/12/21 and the bedside table was positioned over R1's legs, which left R1 restrained. ***Continued on LIC 9099C*** Substantiated ***Continued from LIC 9099*** R1's arms were resting on top of the table. The table was lowered all the way down on top of R1's legs and the table could not be moved. The table was positioned by Staff 1 (S1)The administrator stated that he was only notified of one incident that occurred on 1/8/21. The administrator provided additional abuse training to S1 on 1/8/21. S1 left their position at the facility on 3/1/21. Based on interviews conducted, this allegation is substantiated. Facility does not have hot water: On 1/7/21 and 1/8/21, R1's hospice aide visited the facility and observed that the facility did not have hot water. The hospice aide checked both bathrooms and was not able to produce hot water. R1's social worker accompanied the hospice aide on a visit to the facility on 1/8/21 and confirmed that there was no hot water in the facility. The administrator stated he installed a digital tankless water heater to correct the issue. Based on the LPA's observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC9099D. During the visit on 11/8/21, LPA Henry was able to confirm that the facility has hot water. An exit interview was conducted where this report, LIC 9099D, LIC 811 and appeal rights were provided to Floreline Esteban.the state’s words, verbatim · CDSS document, Nov 8, 2021 · control 18-AS-20210107155833

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Nov 8, 2021

Personal Rights of Residents: Residents...shall...be free from punishment, humiliation, intimidation, abuse... This requirement was not met as evidenced by: Based of interviews and record review, On 1/12/21 Staff 1(S1) placed Resident 1(R1)'s bedside table over R1's legs as a restraint. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 8, 2021

Plan of correction: The facility will provide elder abuse training to staff and provide proof to the department by the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Nov 8, 2021

Maintenance and Operation.The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on interviews and record review, the facility failed to maintain hot water on 17/21 and 1/8/21. Thethe state’s words, verbatim · CDSS document, Nov 8, 2021

Plan of correction: The facility will ensure the maintenance of the hot water system. The facility will provide proof of correction to the department by the POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA was met by caregiver Floreline Esteban. Administrator Felicitas Mabbayad was contacted by Esteban and arrived Mabbayad arrived shortly during the visit. There are currently 4 resident in care as the facility. During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPAs observed licensing issued signage throughout the facility and has proper COVID-19 signage posted. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper 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 the proper use and disposal of PPE and 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 clients 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 residents 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 illnesses. Based on the observations made during today’s visit, there were no deficiencies cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided to Felicitas Mabbayad.the state’s words, verbatim · CDSS document, Aug 24, 2021