Greenhaven Place Independent Lvg and Assisted Lvg

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/5/23 at 10am to conduct an investigation of a medication error. LPA met with Bailey Leach, Business Office Director and stated the purpose of the visit. Community Care Licensing (CCL) received an Unusual Incident/Injury Report incident report (LIC624-SIR) dated 9/15/23 regarding resident #1 (R1). The SIR indicated that on 9/12/23, R1 received medication that should have been administered at 11:30am but instead it was administered at 2pm. R1 should have received eye drops during the 2pm medication pass but did not receive that. In essence, Staff #1 (S1) inadvertently switched the medications and times that should have been administered. The responsible parties of R1 and S2, was present with R1 at the time when the medications were questioned by S2. S2 contacted the doctor and placed R1 on 72hr alert charting. There were no adverse reactions to the medication error. S1 was removed from the Medication Technician position and will be re-trained with shadowing. LPA interviewed S1-S3, R1, and responsible parties of R1. Based on the documents submitted to CCL and interviews, the preponderance of evidence standards has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview conducted and a copy of todays’ report provided.the state’s words, verbatim · CDSS document, Oct 5, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Oct 5, 2023

Incidental Medical and Dental Care 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 requirement is not met as evidenced by: Medication was not administered as prescribed to R1 Based on documentation and interviews which confirmed the medication error occurred. This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: Licensee has submitted proof that additional training was provided to S1. POC Cleared prior to today’s visit

Allegation investigated: Facility is not following resident's prescribed diet Facility did not notify POA of hospitalization

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with business office director Bailey Leach and explained the purpose of the visit. This investigation consisted of interviews with staff and a resident, review of facility records and review of resident records. LPA Moleski reviewed an internal incident report regarding a fall suffered by R1 on 9/13/22 and an external incident report faxed to the Community Care Licensing Division (CCLD) on 9/16/22. The internal report states, under a section titled “Name of family member notified”: “Resident did not want to notify daughter. Told med tech & care giver. Daughter is out of state.” The internal report indicates that R1 was taken to the hospital for treatment. [continued on 9099-C] Substantiated The external incident report does not note any contacts made with family members. Under a section titled “Agencies/individuals notified,” the author of the report only indicated that CCLD was notified. Under a section titled “Explain what immediate action was taken (include persons contacted),” the incident report states that the resident was evaluated by a staff member and emergency responders were called. The report does not state any further contacts were made. LPA Moleski interviewed a former executive director (ED1), who indicated that, to his knowledge, no report was made to R1’s family members. R1’s power of attorney (POA) said she was not notified by the facility of the incident. LPA Moleski reviewed a random sampling of four incident reports from August and September 2022 from this facility, including another incident report involving R1, and found that four of these reports identified a responsible party who was contacted. During interviews, a former executive director (ED2) and two former staff members (S3, S8) were unsure if notification was made to R1’s POA. In interviews, ED1 said R1 was given food items contrary to R1’s prescribed diet, such as high-sugar foods. Another former executive director, (ED2) said the same. Two of two dining staff members interviewed (S5, S6) also said R1 was given food items contrary to R1’s prescribed diet, such as dairy products and high-sugar foods. Meal tickets for R1 reviewed by LPA Moleski often included requests for creamer. During an interview, R1 said she was served dairy products. R1’s LIC 602 dated 12/16/22 states that R1 is allergic to milk and milk products, among other things. R1’s functional needs assessment, dated 12/22/22, indicates that R1 needed a diabetic diet. The department has determined the following as it relates to the allegations that the facility is not following resident’s prescribed diet and that the facility did not notify POA of hospitalization: Based on interviews and review of facility records, the above allegations are SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Sections 87211(a)(1)(B) and 87555(b)(7). An exit interview was held with Leach. Appeal rights and a copy of this report were left with Leach. LPA Moleski reviewed an external incident report that was faxed to the Community Care Licensing Division on 9/16/22. According to this report, R1 was walking to the couch in the living room of R1’s apartment and fell. According to this report, R1 was not wearing a call button pendant at the time of the fall. LPA Moleski interviewed a staff member (S3) who responded after R1’s fall. S3 said there weren’t any fall risk hazards present in R1’s room at the time. LPA Moleski interviewed seven residents (R2-R8). R2 said there was adequate staffing but call response times were an issue. R4 expressed concerns regarding staffing and call response times. R7 said there was adequate staffing when staff are available, but when staff call out there are not enough staff to fill in. R7 did not voice concerns regarding call button response times. R3, R5, R6, and R8 did not express concerns regarding the current levels of staffing or call button response times. LPA Moleski interviewed four staff members regarding staffing levels. S3 and S4 did not voice concerns regarding staffing or call button response times. S5 and S6 did not voice concerns regarding staffing. LPA Moleski reviewed call button response times recorded for the rooms R1 lived in. The average response times for R1’s rooms were all below five minutes. LPA Moleski interviewed two former executive directors (ED1, ED2) regarding contacts made with an ombudsperson. Both ED1 and ED2 said they were not aware of any request to forward information to an ombudsperson. LPA Moleski interviewed an ombudsperson, who was not aware of any such request. LPA Moleski reviewed an email between ED2 and R1’s power of attorney (POA) dated 9/1/22, in which ED2 provided a phone number in response to a request for contact information for the ombudsman’s office. LPA Moleski reviewed a letter addressed to R1 and R1’s POA, dated 8/31/22. The letter describes an increase in rent prices and provides an explanation for the increase. According to the letter, the increase was to go into effect as of November 1, 2022. An address was listed at the top of this letter. During an interview, R1’s POA said this was a mailing address for R1 and R1’s POA. R1’s POA said they never received the letter. [continued on 9099-C] While inspecting R1’s room on 5/12/23, LPA Moleski observed posters affixed to the interior of R1’s apartment door. The posters contained information regarding fire drills. The posters direct the reader on what to do in the case a fire alarm goes off. If a fire alarm is set off, residents are to stay in their room if safe and await further instructions from staff, according to this poster. LPA Moleski interviewed a former executive director (ED1) regarding further instructions in the event that staff do not provide further instructions. ED1 said residents were given further information at three town hall meetings. LPA Moleski reviewed town hall meeting notes for meetings held on 1/26/23, 2/23/23, and 3/23/23. The notes indicate that fire drill instructions were discussed during each of these meetings. ED1 said that, during the January and February meetings, residents were instructed to consider the situation all-clear if there are no further instructions. The department has determined the following as it relates to the allegations that the facility is not adequately staffed, that the facility does not respond to call pendants timely, that the facility did not ensure resident safety resulting in serious injuries, false statement, that the facility did not provide explanation of increase in rent to POA, and that the facility did not ensure resident received instructions during fire drill: Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was held and a copy of this report was left with Leach. During an interview, S7 said the breaker flipped in this room once or twice due to the devices that were plugged in. S7 said staff were directed to utilize another outlet and had no issues afterward. LPA Moleski reviewed an incident report from this facility that described an incident on 8/8/22 wherein a water heater leaked into R1’s bedroom. The incident report describes steps taken by this facility to address the leak. LPA Moleski inspected the room where the leak occurred and observed no physical plant deficiencies. LPA Moleski reviewed staff transfer training records dated January 25, 2023 and an all-staff training sign-in sheet dated April 26, 2023. LPA Moleski reviewed an incident report regarding a fall suffered by R1 on 9/13/22. The incident report was received by the Community Care Licensing Division (CCLD) via fax as of 9/16/22. The department has determined the following as it relates to the allegations that the facility is not addressing physical plant problems, that the facility is not providing training for resident transfers, and that the facility is not reporting incidents to CCLD: Based on observation, review of facility records, review of licensing records, and staff interview, the above allegations are UNFOUNDED. A finding that the complaint allegations are unfounded means the allegations are false, could not have happened or are without a reasonable basis. An exit interview was held and a copy of this report was left with Leach.the state’s words, verbatim · CDSS document, Sep 14, 2023 · control 27-AS-20230427160250

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Sep 29, 2023

Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision." This requirement was not met as evidenced by: Based on interviews and record review, R1's POA was not notified after R1 suffered a serious injury at this facility, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Sep 14, 2023

Plan of correction: Licensee agrees to conduct an in-service staff training on reporting requirements. Licensee further agrees to send LPA Moleski a copy of a sign-in sheet for this training by the POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Sep 29, 2023

Food Service: "(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided." This requirement was not met as evidenced by: Based on record review and interviews, R1 was provided food contrary to doctor's orders, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Sep 14, 2023

Plan of correction: Licensee agrees to conduct an in-service staff training on food service requirements. Licensee further agrees to send LPA Moleski a copy of a sign-in sheet for this training by the POC due date. vincent.moleski@dss.ca.gov

Allegation investigated: Facility is retaliating against resident for RP filing previous complaint Staff are touching resident inappropriately

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with business office director Bailey Leach and explained the purpose of the visit. This investigation consisted of interviews with staff and residents, review of personnel records and review of facility records. LPA Moleski reviewed communications between R1’s POA and a former executive director (ED1). During interviews, ED1, S1, and S2 denied retaliation after receiving a prior complaint. [continued on 9099-C] Unsubstantiated LPA Moleski reviewed an internal incident report regarding an incident which occurred on January 15, 2023. The report stated that R1 shoved S9 while S9 was clearing R1’s call button. LPA Moleski interviewed four staff members (S1, S2, S10 and S11) and five residents (R2, R3, R9, R10, and R11) regarding S9. None of the five residents voiced concerns regarding inappropriate touching from S9. None of the four staff members voiced concerns regarding inappropriate touching from S9. In an interview, S9 denied having inappropriately touched R1. LPA Moleski reviewed S9’s personnel file and did not observe any poor performance reviews or disciplinary actions. The department has determined the following as it relates to the allegations that the facility is retaliating against resident for RP filing previous complaint and that staff are touching resident inappropriately: Based on record review and interviews with residents and staff, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was held and a copy of this report was left with Leach. Based on observation, the above allegation is UNFOUNDED. A finding that the complaint allegation is unfounded means the allegation is false, could not have happened or is without a reasonable basis. An exit interview was held and a copy of this report was left with Leach.the state’s words, verbatim · CDSS document, Sep 14, 2023 · control 27-AS-20230512115316

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(LPA) Victoria Brown arrived unannounced on 8/30/23 at 11am to obtain additional information regarding a Special Incident report (SIR-LIC624) received by Community Care Licensing (CCL) on 8/28/23. The SIR stated that a medication error occurred where as resident #1(R1) received R2's medication. LPA interviewed Staff #1 (S1)-(S3) and (R1)-(R2) and reviewed the medication process with S2 during this visit. Based on the documents submitted to CCL and interviews, the preponderance of evidence standards has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Facility Designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.the state’s words, verbatim · CDSS document, Aug 30, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(j) · Plan of correction due date: Aug 30, 2023

Incidental Medical and Dental Care In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring ... assisting residents as needed with self-administration of medications... This requirement is not met as evidenced by: medication that belonged to R2 was administered to R1 and there was no adverse reaction Based on documentation which confirmed the medication error occurred This violation poses an potential health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 30, 2023

Plan of correction: Licensee has submitted proof that a review of medication administration practices was conducted. POC Cleared prior to todays visit

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 1/13/23 at 11:45AM. LPA met with Robert Coe, Administrator and stated the purpose of todays visit. LPA toured and inspected the physical plant to ensure there are no safety hazards to residents. The facility has 1 residents receiving hospice care services at this time. Administrator Certificate expires 1/10/2025. LPA observed and interviewed residents during this visit. The temperature inside the facility was observed to be at 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 120.0*F during this visit which is within the required range of 105-120*F. LPA observed a random amount of rooms during this visit. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed 2-day perishables and 7-day non-perishables. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 13, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/24/22 at 1:00p on a subsequent Case Management visit. LPA met with Robert Coe and stated the purpose of the visit. Community Care Licensing (CCL) received a incident report (LIC624) on 3/31/2022 regarding a resident stating that a caregiver was verbally aggressive while assisting with care needs. LPA obtained information that S2 is no longer working at the facility and the contact information has changed. LPA was unable to interview S2. S1 stated during this visit that S2 upon an investigation did not confirm or deny being verbally aggressive but admitted to being frustrated one night. After being pulled from the floor S2 resigned from working at the facility. R1 stated the caregiver no longer works for the facility and everyone is very helpful and that S2 was not feeling well that day. Based on the information reviewed and obtained, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged abuse occurred and that the facility is at fault for any deficiencies regarding Title 22 regulations. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit.the state’s words, verbatim · CDSS document, Oct 24, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/24/22 at 1:00p to conduct a Case Management visit. LPA met with Robert Coe and stated the purpose of the visit. Community Care Licensing (CCL) received a incident report (LIC624) on 3/25/2022 regarding a resident stating that a caregiver was physically abusive. S1 stated R1 did not report the persons name but said during the night of the funeral the pendant couldn't be located and staff came in and punched the stomach. R1 stated to S1 the facility should know what's happening in the facility there is no need to report things. S1 stated that the funeral was at least 1 month prior to the report of abuse. R1 refused to be interviewed and stated that happened 1 year ago under a different management. Based on the information reviewed and obtained, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged abuse occurred and that the facility is at fault for any deficiencies regarding Title 22 regulations. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit.the state’s words, verbatim · CDSS document, Oct 24, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/23/22 at 9:30a to obtain information regarding an incident report submitted to Community Care Licensing (CCL) regarding Resident #1 (R1). LPA met with Regina Farinias, Marketing Director and stated the purpose of the visit. The incident report indicated that the police arrived to obtain information for resident #1 (R1) as R1 was in a car accident on or about 9/15/22. LPA requested and obtained a copy of R1's Identification and Emergency Information (LIC601) dated 2/4/22, Physician report(s) (LIC602A) dated 1/20/22, 4/15/22, 4/27/22, Preplacement Appraisal (LIC 603) dated 2/4/22, Drivers License, and Out patient medications list. LPA conducted interviews of staff #1 (S1-S3) and R1 during this visit. A review of documentation provided revealed that R1's physician reports all indicate that R1 is able to leave facility unassisted with supervision. It also indicates that R1 is diagnosed with Mild Cognitive Impairment (MCI). The Preplacement Appraisal indicates resident can be a bit confused at times. The investigation revealed that R1 was driving alone and had an accident with no major injuries. Although R1 continued to drive a personal vehicle, the LIC602 indicates that R1 needed supervision. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Staff was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Sep 23, 2022

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87466 · Plan of correction due date: Sep 26, 2022

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...deterioration of mental ability...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: R1 having a car accident while driving alone. Based on interviews confirming R1 was driving alone facility did not ensure supervision as stated on LIC602. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2022

Plan of correction: Licensee shall conduct a care meeting with resident and responsible party and ensure the resident is receiveing the care specified on the LIC602. A letter of understanding shall be faxed to the CCL office by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/23/22 at 9:30a LPA met with Regina Farinias, Marketing Director and stated the purpose of the visit. LPA inquired about a Designation of Facility Responsibility (LIC308) and the staff was unsure of the document being requested. On 9/13/22, LPA was informed that the Administrator would no longer be working at this facility. On 9/14/22, LPA received a call from the Corporate Office indicating a new Administrator would be hired. On the same date, LPA emailed the pertinent documents that would be needed to change the Administrator on record with the Department. On 9/21/22, LPA emailed Corporate Office inquiring about the documents. During todays subsequent visit, LPA received an email indicating the documents for a new Administrator will be provided to Community Care Licensing (CCL) by the week of 9/26/22. The email that was sent by LPA contained the following information: Here is the information to change a administrator. Please ensure there is an LIC308 in effect. Here is the information that need to be submitted to avoid a citation in the event that a change is necessary. Please ensure the person is fingerprint cleared and associated to the facility through your Guardian account, and submit the documents mentioned below. At which time I can process the change. These documents are to be submitted as well as notification to the Department any time there is a change or intended change in the Administrator and/or Executive Director. Administrator Certificate, Personnel Record (LIC501), Health Screening with TB (LIC503), CPR/First Aid, Criminal record statement (LIC508), -Designation (LIC308), -A letter from the Licensee appointing the person to be able to speak on behalf of the Licensee. Updated Personnel Report (LIC500) showing the Administrator on schedule in the facility 40hrs per week To date, the Department has not received for 10 days a Designation of Facility Responsibility (LIC308) nor documentation of an administrator with the supporting documents. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Staff was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Sep 23, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Sep 26, 2022

Administrator - Qualifications and Duties All facilities shall have a qualified and currently certified administrator...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... This requirement is not met as evidenced by: Staff was unsure of the Designation form for who is in charge at this time. Based on No LIC308 posted or made available and no Administrator either hired or on premisis. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2022

Plan of correction: Licensee shall submit an LIC308 to CCL via fax and ensure the regulations are being followed. Fax by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to obtain information regarding an incident report submitted to Community Care Licensing (CCL) regarding Resident #1 (R1). LPA met with Administrator (Adm) Frances Santillan and stated the purpose of the visit. LPA conducted interviews of Adm, R1, and Police Department during this visit. LPA obtained a copy of R1's Identification and Emergency Information (LIC601), Release of Client/Resident Medical Information (LIC 605), Physician report (LIC602A) dated 7/12/21, Resident Emergency Form dated 3/10/22, Resident Emergency Form dated 7/22/21, Preplacement Appraisal (LIC 603), Durable Power of Attorney (POA) dated 8/1/2007, email between Adm and R1's emergency contact dated 1/21/22, A letter indicating to add a person to R1's contact list to call for emergencies that did not include a date or signature, a copy of the SOC341 and Incident Report submitted to CCL and Long Term Care Ombudsman (LTCO) on 1/21/22, an email between Adm and R1's emergency contact dated 1/19/22 indicating a concern about charges on R1's bank card $2500, on 1/5/22, $3620 (twice) on 1/16/22, Police report dated 1/21/22 filed online, POA for Health Care with Advance Heath Care Directives dated 1/26/22, email between Adm and R1's emergency contact dated 2/8/22 indicating no longer able to pay bills for R1 and has been removed from access. Resident Evaluation dated 2/21/22, a fax to R1's Primary Care Physician indicating very confused requesting a video appointment dated 2/22/22, a fax to CCL indicating a call was received from R1's bank during this visit. A review of R1's physician report indicates that R1 is able to manage own cash resources and able to leave facility unassisted. It also indicates that R1 is confused and/or disoriented. The investigation revealed that a review of all documents mentioned above, the facility has not violated any Title 22 regulations and is working with Adult Protective Services (APS), PCP, and Law Enforcement to ensure R1 remains safe physically and monetarily while residing in the facility. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 10, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst(s) (LPA) Victoria Brown and Jamie Ivey Canady arrived unannounced to conduct a Required Annual visit on 1/20/22 at 1:30PM. LPAs met with Frances Santillan, Administrator and stated the purpose of todays visit. LPAs toured and inspected the physical plant to ensure there are no safety hazards to residents. The facility has 2 residents receiving hospice care services at this time. Administrator Certificate expires 10/21/22. LPAs observed and interviewed residents during this visit. The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 115.4*F during this visit which is within the required range of 105-120*F. LPAs observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPAs observed 2-day perishables and 7-day non-perishables. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 20, 2022

Allegation investigated: Staff intimidate resident(s). Residents are not being provided adequate food service. Facility is not conducting fire drills as required.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the complaint investigation on the above mentioned allegations on 11/3/21 at 9:30am. LPA met with Francis Santillan and stated the purpose of today’s visit. LPA conducted interviews of Staff #1 (S1-S7) and Resident #1 (R1), POA, and Private Caregiver (PC) of R1 during this visit. Regarding allegation "Staff intimidate resident(s)", LPA was told by R1 with a raised voice that LPA could not be understood while using the mask. LPA spoke louder and asked the PC if R1 wore a hearing aid. The PC put in the hearing aid for R1, and R1 was able to understand LPA during interview. The Power of Attorney for R1 stated that everyone has to speak louder due to R1 being hard of hearing. R1 stated a creamer was used by R1 in a soup to make a cream of tomato soup and no one restricted R1 from doing so. R1 stated that staff has not been intimidating. LPA conducted interviews of S1-S7. The investigation revealed that all staff, R1, POA, and Administrator concur that staff are not intimidating the residents. Unfounded Regarding allegation "Residents are not being provided adequate food service" In reviewing the Diet Clarification Form dated 6/3/21, R1 can self manage diet and the Physician report dated 6/3/21 indicates R1 is not on a special diet. The facility has a Dietician and a Dining Services Director who over sees the menus and the dining staff. LPA observed there are sample entrees prepared for residents to see visually and there are alternatives and off the menu items offered as well. In addition, a weekly menu is given to all residents to assist in their decision for meals. Residents are able to complete a room service delivery slip or verbalize their preferences to staff. LPA conducted interviews, obtained information, and observed that this facility utilizes a computerized system that will not allow a printed menu with too many carbohydrates, too much sodium, or calories on any given day. It is set up to only allow balanced meals to be added to the menus. If an unbalanced menu occurs then the system flags red and will not print out the menu until the menu is corrected. Regarding allegation "Facility is not conducting fire drills as required" LPA conducted interviews and observed the training documents that were signed by each staff in attendance for the in-services. LPA received documentation of drills and in-services conducted from 3/24/21 through 9/22/21. The training's were on the following topics: Verbal Fire Drill, Elopement Drill, Behavioral Management, Medication, Resident Rights, Mandated Reporting, and Emergency Preparedness Drills and Exercise that was conducted. The investigation revealed that the materials are reviewed and the trial run is conducted with staff to ensure knowledge on tasks and how to assist residents efficiently. Based on interviews and observation of documentation, the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNFOUNDED. “This agency has investigated the complaint alleging, the above-mentioned allegation(s). 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. We have therefore dismissed the complaint.” Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 3, 2021 · control 27-AS-20210913100845

Allegation investigated: Staff mishandled a resident's medication while in care Staff did not prevent a resident from wandering Staff did not properly report an incident involving a resident while in care

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above mentioned allegations on 9/28/21 at 1:30pm. LPA met with Frances Santillian and discussed the purpose of the visit. In regards to the allegation, "Staff mishandled a resident's medication while in care", LPA received an Incident Report indicating that several medications had not been administered to Resident #1 (R1) from 3/14/21 to 4/20/21. Although the facility contacted the pharmacy on 3/27/21 and 4/16/21 to order medications, the Administrator was not made aware until 4/19/21, and there was no indication that the family or physician was made aware. Allegation deemed SUBSTANTIATED Substantiated In regards to the allegation, "Staff did not prevent a resident from wandering", LPA received a call from the Administrator and an Incident Report stating that R1 had eloped from the facility. At 8pm R1 was seen by the police who contacted the facility to identify R1. R1 sustained no apparent inuries but was confused. A review of R1's Physician Report dated 12/4/2020 revealed that R1 was diagnosed with Mild Cognitive Impairment (MCI), confused at times due to diagnosis of Parkinsins and unable to leave the facility unassisted. LPA also received a copy of the call log from Sacramento Police Department indicating that on 4/12/21, R1 was located and returned to the facility. Allegation deemed SUBSTANTIATED In regards to the allegation, "Staff did not properly report an incident involving a resident while in care", LPA obtained information that the responsible party requested a copy of any changes for R1, medication records and documentation of incidents where R1 was exit seeking, the documents were not provided. Allegation deemed SUBSTANTIATED Based on documentation the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.the state’s words, verbatim · CDSS document, Sep 28, 2021 · control 27-AS-20210426144251

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(1-3) · Plan of correction due date: Sep 29, 2021

Incidental Medical and Dental Care If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Facility documentation, R1 did not receive medication (s). timely. The Licensee did not refill medication or administer medications as prescribed. This possess an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2021

Plan of correction: Licensee/Administrator conducted in-service training for all staff on 4/6/21, 5/28/21, 6/17/21, 6/18/21, 7/28/21, and 9/22/21 regarding Resident Rights, Dignity and Elder abuse, Elopement, Behavorial Managment, Emergency Drills and Medication. POC cleared prior to todays visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 29, 2021

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Facility documentation, R1 was absent without leave (AWOL). The Licensee failed to adequately supervise R1 which allowed for R1’s elopement from the facility. This possess an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2021

Plan of correction: Licensee/Administrator conducted in-service training for all staff on 4/6/21, 5/28/21, 6/17/21, 6/18/21, 7/28/21, 9/22/21 regarding Resident Rights, Dignity and Elder abuse, Elopement, Behavorial Managment, Emergency Drills and Medication. POC cleared prior to todays visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Sep 29, 2021

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidenced by: R1's representative did not receive requested records. The Licensee failed to provide records for R1 as requested by representative. This possess an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2021

Plan of correction: Licensee shall provide R1's March and April 2021 facility records to Representaive. A letter of confirmation shall be submitted to CCL by POC due date.