Signature Living on Story Ridge Way

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived on 09/05/2023 to conduct the annual inspection. LPA met with administrator, Scott Afable who assisted LPA during today's inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (2) and staff files (2). All residents files contained the required paperwork. Staff file contained the required paperwork. Staff have current first aid and CPR training. Facility was clean. All required posting were observed. Staff training contained the required initial and annual training. LPA reviewed medications of 2 residents comparing with physician orders and find no errors. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. There is a gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use and was last serviced on 05/26/23 . Water temperature is within compliance (114 degree F) .Inside temperature was observed to be 73 degree*F. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 09/15/23. No deficiencies were observed or cited during today's visit. Exit interview conducted. A copy of this report was printed and given to Administrator.the state’s words, verbatim · CDSS document, Sep 5, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/15/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with administrator- Scott Afable and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA confirmed that facility does not any positive covid-19 cases and nobody is experiencing any covid-19 symptoms today before facility entry. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. LPA was screened by facility staff upon entry. LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 6 resident bedrooms, 2 bathrooms, kitchen, common area, dining area ,medication closet , laundry area and backyard area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection however Technical Advisory has been issued. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Sep 15, 2022

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff sexually abused resident while in care.

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Nerry Rimando-Afable, to deliver findings into the complaint allegation listed above. Facility currently does not have any COVID-19 positive cases. LPA wore N-95 mask and was screened by facility upon entry. Facility staff wore masks in the care home. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. Allegation: Staff sexually abused resident while in care ** Report continued on 9099-C ** Unsubstantiated Resident (R1) reported that staff member (S1) had touched R1’s genital area over their clothing. R1 pushed S1’s hand away and told them to stop. R1 also alleged that S1 had attempted to remove R1’s underwear while assisting R1 with showering. R1’s statement regarding sexual abuse coincides with prior statements made by R1 and provided to Sacramento County Sheriff’s Department. S1 denied touching R1’s genital area or doing anything inappropriate with R1. S1 reported that R1 refused to remove their underwear while showering and S1 did not interfere with R1 keeping their underwear on while showering. Interviews conducted with staff indicated that no staff member had witnessed the alleged incident and staff did not have any complaints against S1. Interviews conducted with residents indicated that no resident had direct knowledge of the alleged incident and residents did not have any concerns regarding the care provided by S1. Sacramento County Sheriff’s Department suspended their case regarding the alleged incident. Based on interviews conducted by the Department and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Nov 24, 2021 · control 25-AS-20210727155253

Type of visit: POC

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Nerry Rimando-Afable, to conduct a Plan of Correction (POC) visit. Facility currently does not have any COVID-19 positive cases. LPA wore N-95 mask and was screened by facility upon entry. Facility staff wore masks in the care home. Prior to visit, LPA obtained a copy of the Statement of Understanding regarding 87307(a) 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. Statement states that "staff will no longer be allowed to sleep inside the garage and all personal belongings will be removed immediately. The garage will solely be used as storage, as it was intended." LPA observed garage and found that all staff belongings have been removed. POC was cleared during visit. No additional deficiencies were issued during visit. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Nov 24, 2021

Allegation investigated: Resident sustained unexplained injuries while in care. Resident has sustained multiple unwitnessed falls while in care. Facility failed to report incident(s).

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Nerry Rimando-Afable, to deliver findings into the complaint allegations listed above. Facility currently does not have any COVID-19 positive cases. LPA wore N-95 mask and was screened by facility upon entry. Facility staff wore masks in the care home. During the investigation, LPA toured the facility, reviewed documentation pertinent to the investigation, and interviewed facility staff, residents, and relevant parties. Allegation: Resident sustained unexplained injuries while in care. ** Report continued on 9099-C ** Unsubstantiated Interviews with residents (R2, R3, R4) and staff members (S1, S2, S3, S4) indicated that there have been no witnessed instances of staff being rough with residents while receiving care. Review of documentation from hospice care and interview with hospice representative indicated that no unexplained injuries occurred while resident (R1) was receiving care at the facility. Staff care notes from the facility match care notes from hospice services. Allegation: Resident has sustained multiple unwitnessed falls while in care. Interviews with R2, R3, R4, S2, S3, S4, and relevant parties indicated that there have not been any witnessed or unwitnessed instances of a resident falling while at the facility. Interviews with R2, R3, R4, S2, S3, S4, and relevant parties also indicate that there have not been any witnessed or unwitnessed instances of R1 falling while living at the facility. Allegation: Facility failed to report incident(s). Documentation from hospice care and interview with hospice representative indicates that there have not been any incidents regarding R1 that have not been reported to relevant parties. Hospice documentation indicates that one stage 1 decubitus ulcer sustained by R1 was reported to R1's family. Interviews with staff members S1, S2, S3, S4, and Administrator demonstrate that facility is aware of when to report an incident to Community Care Licensing. Based on interviews conducted by LPA, observations during inspection, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Nov 15, 2021 · control 25-AS-20210720110625

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Michael Hood arrived at the facility and met with Administrator, Nerry Rimando-Afable, to follow-up regarding information received from a previous interview conducted. Facility currently does not have any COVID-19 positive cases. LPA wore N-95 mask and was screened by facility upon entry. Facility staff wore masks in the care home. During previous interviews conducted with relevant parties, it was discovered that staff may have not reported incident to Community Care Licensing. LPA conducted interview with staff member (S1), Administrator, and received contact information for former resident (R1). At this time, further investigation is needed regarding information above. During previous interviews conducted, it was discovered that staff may be sleeping at the facility when there is not a designated staff member bedroom. LPA observed garage with bed and dresser. Administrator stated that staff had previously slept in garage but were instructed that they may no longer use the garage as a bedroom and must move their belongings. LPA observed facility sketch and found that garage was listed as "storage" and not approved as a designated staff member bedroom for staff to sleep in. Due to interviews previously conducted, documents reviewed, and LPA's observation, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page due to staff sleeping at the facility when facility does not have an approved staff member bedroom. Exit interview was conducted with Administrator and a copy of this report and appeal rights were provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Nov 15, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a) · Plan of correction due date: Nov 24, 2021

87307 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. This requirement is not met as evidenced by: Based on interviews conducted and observations, facility did not ensure that staff were not sleeping in the facility's garage, which is indicated as a "storage" on the facility's sketch, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2021

Plan of correction: Administrator will complete a statement of understanding indicating that staff will no longer sleep in the garage. Administrator will submit statement of understanding and staff will remove belongings from garage by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Williams arrived at the facility unannounced on 10/26/2021 to conduct a Required 1- Year Inspection utilizing the infection control domain. LPA met with Administrator, Nerry Rimando, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entering the facility. LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Oct 26, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Williams arrived at the facility unannounced on 07/27/2021 to conduct a Required 1- Year Inspection utilizing the infection control domain. LPA met with Administrator, Nerry Rose, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entering the facility. LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jul 27, 2021