Lillie Care Home

Allegation investigated: Staff spoke inappropriately towards resident

Licensing Program Analyst (LPA) Tung Truong made an unannounced visit to the facility to commence a complaint investigation for the above allegation. LPA met with facility staff Darlene Boyd and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on records reviewed and interviews conducted, staff (S1) spoke to client (C1) inappropriately on 10/23/23. According to a voicemail, S1 can be heard talking to C1 in a degrading manner. S1 told C1 that she is lazy, and that other care home would not put up with her behavior. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. Exit interview was conducted, a copy of the report, LIC 9099-D and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Nov 2, 2023 · control 27-AS-20231026091124

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 9, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews and records review, the Licensee did not ensure residents were accorded dignity by Staff (S1). S1 spoke to C1 inappropriately on 10/23/23. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2023

Plan of correction: All staff and administrator shall take In-Service training on verbal abuse, and residents personal rights. Administrator shall send proof of training to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Avelina Martinez and Scott Brooks made an unannounced visit to this facility to conduct an annual inspection on 10/19/2023 at 2:25 PM. LPA Martinez met with Renee Ates and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. Administrator holds current certificate and expires in September of 2024. The facility is licensed for 6 non-ambulatory clients. There are currently 4 clients who reside at this facility. The facility has a hospice waiver for 1. LPA Martinez toured the facility with on 10/19/2023 at 2:25 PM. LPA Martinez reviewed two employee files and two client files, and the files were maintained. LPA Martinez reviewed one medication administration record, and the record was maintained. First Aid Kit was complete. The fire extinguishers, smoke detectors, and carbon detectors were in good repair. Facility has cameras mounted in the common areas. The cameras are not in working order, however, facility sketch should be updated to reflect mounted cameras. LPA Martinez requested a copy of surety bond and liability insurance The facility has infection control plan and emergency disaster plan. All requested document should be emailed to LPA Martinez by October 26 2023 by 5 PM. LPA observed the facility to have an adequate food supply. The following items were not in good repair: Window screens, sliding glass door screens, exterior fence, wheelchair ramp, emergency exit gate/door, freezer had frost bite build up. The items should be repaired by November, 09, 2023. A Plan of correction visit will be conducted to inspect repairs. The facility water temperature measured at 105 degrees and facility temperature measured at 78 degrees. As a result, of this annual visit, the facility was cited for fire clearance and Maintenance and Operation. Citations can be found on the 809-D page. An exit interview was conducted, and a copy of this 809 report, 809-D Page, and appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Nov 9, 2023

87303 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 requirement was not met as evidence by Based on observation and inspection, LPA Martinez found the following items not to be in good repair: Facility window screens, exterior emergency door ramp, exterior fence boards broken and nails exposed, freezer has frost bite. This posed a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Nov 9, 2023

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 requirement was not met as evidence by: Based on observation and inspection the exterior emergency/fire gate was not in good repair. This posed a potential health and safety risk to client.the state’s words, verbatim · CDSS document, Oct 19, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 12/7/2022 to conduct a case management visit. Upon LPAs arrival, Caregiver Shaquita Haywood was present and contacted facility staff Renee Ates who arrived a bit later. LPA met with Renee Ates and explained the purpose of the visit. There are currently 4 residents who reside at this facility. The purpose of the visit today is in response to substantial inadequacies identified by Alta California Regional Center during an annual Title 17 Monitoring Review on 11/21/2022. It was learned that the facility was placed on sanction on 12/6/2022 due to the following deficiencies: - Failure to provide consumer services as specified in the consumer’s IPP. - Failure to comply with the requirements for administrator and staff qualifications and/or administrator and staff training. - Failure to ensure that a direct care staff completes the competency based training and testing required. As a result, the following deficiencies were cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page. Exit interview was conducted, a copy of this report, 809-D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 7, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(h)(4)(5) · Plan of correction due date: Dec 15, 2022

Administrator - Qualifications and Duties. The administrator shall perform the following duties…(4) Recruit, employ and train qualified staff… (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs. This requirement is not met as evidenced by: Based on records review, the licensee did not ensure client's medication reason of use is filed and direct care staff completes the competency-based training and testing as required. This poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Dec 7, 2022

Plan of correction: Licensee/Administrator shall submit to LPA a written statement of understanding regarding Administrator Qualifications and Duties regulation section 87405 and its requirements by POC due date.

Type of visit: Required - 1 Year

On 10/07/2022 at 1:50 pm, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA Truong called the facility and spoke to staff who confirmed no residents or staff have had any symptoms of COVID-19 in the last 10 days. LPA met with Administrator Renee Ates explained the purpose of the visit. Administrator holds current certification #6021935740 and expires on 9/20/2022. Administrator stated her renewal application was submitted early September. The facility is licensed to serve six (6) non-ambulatory residents. Hospice waiver approved for 2. There are currently four (4) residents who reside at this facility. LPA toured the facility with Renee Ates on 10/07/2022 at 2:10 pm. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 112.0 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 75 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. Continued on 809-C LPA observed knives were locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA observed toxins were not locked and accessible to residents. LPA also conducted the infection control domain tool. The facility mitigation plan was submitted to CCLD, and it was approved on 4/27/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan. Per California Code of Regulations, Title 22, deficiencies were observed and cited on the 809-D during this visit. Exit interview was held, a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Oct 7, 2022

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 10/21/2021 at 8:45 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA Truong called the facility and spoke to Lillie Williams, who confirmed no residents or staff have had any symptoms of COVID-19 in the last 10 days. Upon LPAs arrival, Caregiver Carol Parks was present at facility and contacted Administrator Renee Ates who arrived a bit later. LPA met with Administrator Renee Ates explained the purpose of the visit. Administrator holds current certification #6021935740 and expires on 9/20/2022. The facility is licensed to serve six (6) non-ambulatory residents. Hospice waiver approved for 2. There are currently five (5) residents who reside at this facility. LPA toured the facility with Renee Ates on 10/21/2021 at 9:15 am. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, staff room, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 114.1 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to residents. Report continued on 809-C Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA also conducted the infection control domain tool. The facility mitigation plan was submitted to CCLD, and it was approved on 5/8/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan. Administrator was informed to send updated copies of the following documents to CCL within 15 days: (1) LIC308 Designation of Administrative Responsibility (2) LIC500 Personnel Report (3) Copy of Administrator Certificate (4) LIC610 Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC309 Administrative Organization Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited during this visit. An exit interview was held with Renee Ates and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 21, 2021

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.