Love and Serenity II

Type of visit: Case Management - Health Checks

On 8/11/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a health and safety check. LPA met with Assistant Administrator Adi Lina Tuiloma and explained the purpose of the visit. The purpose of the visit today is in response to Administrator Unaisi Waqalala request for licensing forms to change facility administrator on 7/27/23. It was learned during today’s visit that Unaisi Waqalala is still the facility administrator at this time. Administrator Unaisi advised that she will submit the request for change of administrator once all the paperwork is completed. LPA briefly toured the physical plant to ensure compliance with Title 22 regulations. There are currently 4 residents who reside at this facility. There were two staff present during today's visit. LPA observed the facility to be clean and sanitary. LPA observed an adequate supply of food for 4 residents. The temperature inside was set to 78 degrees Fahrenheit. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to residents. No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 11, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tung Truong conducted an unannounced 1 Year Annual Inspection Visit on 1/31/2023. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit. Administrator assisted with today’s visit. Administrator Certificate # 6056441740 expires 7/8/2024. The facility is licensed to serve up to (6) six non-ambulatory residents. Approved hospice waiver for (2) two. There are currently 5 residents who reside at this facility. The facility had COVID -19 posters and signs throughout the facility. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. 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. Report continued on 809-C The hot water temperature was observed to be 116.8 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 81 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 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 residents. LPA observed current liability insurance is up to date. LPA also conducted the infection control domain tool. LPA requested resident and staff files for review. LPA reviewed (2) resident files and (2) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. The following forms and documents were requested to be submitted within 15 days: (1) LIC308 Designation of Administrative Responsibility (2) LIC500 Personnel Report (3) Copy of Administrator Certificate (4) LIC610 Emergency Disaster Plan Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview conducted and copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 31, 2023

Type of visit: Case Management - Other

On 11/7/22 at 9:45 AM, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a quarterly case management inspection due to a current stipulation order. Upon LPAs arrival, Caregivers Lavina Whippy and Lina Tuilona were present at facility and contacted Administrator Unaisi Waqalala who arrived a bit later. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit. Today’s visit which is to ensure the Stipulation Order is being followed. LPA toured and inspected the physical plant to ensure there are no safety hazards to residents. LPA observed posting of the stipulation in an observable place. LPA observed the facility is clean and in good repair. LPA observed facility has auditory device on exit door that can be heard throughout the facility. LPA observed 2 on-duty caregivers during this visit, who are fingerprint cleared. Hot water temperature was measured at 112.5*F during this visit, which is within the required range of 105-120*F. Facility thermostat observed at 72 degrees Fahrenheit. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors are up to date. LPA observed 2-day perishables and 7-day non-perishables. LPA observed centrally stored medications area to be locked and inaccessible to residents. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was held, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Nov 7, 2022

Type of visit: Case Management - Other

On 8/11/22 at 9:40 AM, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a quarterly Case Management inspection due to a current stipulation order. Upon LPAs arrival, Caregivers Joy Waqalala and Lina Tuilona were present at facility and contacted Administrator Unaisi Waqalala who arrived a bit later. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit. Today’s visit which is to ensure the Stipulation Order is being followed. LPA toured and inspected the physical plant to ensure there are no safety hazards to residents. LPA observed posting of the stipulation in an observable place. LPA observed the facility is clean and in good repair. LPA observed facility has auditory device on exit door that can be heard throughout the facility. LPA observed 2 on-duty caregivers during this visit, who are fingerprint cleared. Hot water temperature was measured at 108.1*F during this visit, which is within the required range of 105-120*F. Facility thermostat observed at 76 degrees Fahrenheit. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors are up to date. LPA observed 2-day perishables and 7-day non-perishables. LPA observed centrally stored medications area to be locked and inaccessible to residents. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was held, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Aug 11, 2022

Type of visit: Case Management - Legal/Non-compliance

On 5/4/22 at 1:20 PM, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a quarterly Case Management inspection due to a current stipulation order. Upon LPAs arrival, Caregivers Adi Lina Tuiloma and Angel Joy were present at facility and contacted Administrator Unaisi Waqalala who arrived a bit later. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit. Today’s visit which is to ensure the Stipulation Order is being followed. LPA observed posting of the stipulation. LPA observed facility has auditory device on exit door. LPA toured and inspected the physical plant to ensure there are no safety hazards to residents. LPA observed 6 residents and 2 caregivers during this visit, who are fingerprint cleared. The hot water temperature was measured at 108.9*F during this visit which is within the required range of 105-120*F. 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 centrally stored medications area to be locked and inaccessible to residents. The first aid kit observed and is complete. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was held, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, May 4, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 5/3/22 at 10:10am. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA was met by Angel Joy Waqalala and stated the purpose of the visit. LPA spoke with Administrator Unaisi Waqalala who stated S1 does not work in the facility and has not ever worked in the facility. S1 was not present at the time of visit. Facility understands this is an Immediate Exclusion effective 4/14/2022. S1 is excluded and prohibited from being a licensee, owning a beneficial ownership of 10% interest or more in a licensed facility, or being an Administrator, officer, director, member, or manager of a licensee or entity controlling a licensee. S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held, Copy of report giventhe state’s words, verbatim · CDSS document, May 3, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 5/3/22 at 12:30pm. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA was met by Tevita Kaloulasulasu , Caregiver and stated the purpose of the visit. LPA spoke with Administrator Bianca Castro who stated S1 worked at the facility possibly in 2018 but has not worked since then. S1 was not present at the time of visit. Facility understands this is an Immediate Exclusion effective 4/14/2022. S1 is excluded and prohibited from being a licensee, owning a beneficial ownership of 10% interest or more in a licensed facility, or being an Administrator, officer, director, member, or manager of a licensee or entity controlling a licensee. S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held, Copy of report giventhe state’s words, verbatim · CDSS document, May 3, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management for the purpose of delivering an Order to Licensee/Facility of Immediate Exclusion From Facility. LPA Valerio met with facility staff Susana Masiwala and explained the purpose of today's visit. Facility staff called Administrator Unaisi Waqalala, which designated staff to sign for her. LPA explained the letter over the phone to Administrator Unaisi. LPA Valerio handed the Order to Licensee/Facility of Immediate Exclusion from Facility Letter to facility staff and explained Staff 1 (S1) has been excluded and must be removed from any contact with clients and may not be physically present in any facility. No deficiencies were observed during the visit. A declaration of service was completed for the visit. An exit interview was held, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Apr 26, 2022

Allegation investigated: Staff attempted to rape a resident

Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 04/12/2022 at 9:30 am to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit. The investigation was conducted by the Department which consisted of reviews of the facility records and interviews with facility management, staff and residents. During an interview with R1, R1 did not elaborate or discuss further any concerns about the rape. R1 primary concern is that someone will try to enter the bathroom while she showers despite the bathroom door having a lock on it. Report continued on 9099-C Unsubstantiated As a result of this investigation, the Department finds the allegation above to be UNSUBSTANTIATED- A finding that the complaint 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 Unaisi Waqalala and a copy of the report was provided. As a result of this investigation, the Department finds the 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. The following deficiencies has been cited on Complaint Control # 27-AS-20211228152000, per Title 22 Regulations, Division 6. Exit interview was conducted with Administrator Unaisi Waqalala and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 12, 2022 · control 27-AS-20220315152819

Allegation investigated: Resident sustained pressure injuries while in care.

Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 04/12/2022 at 9:30 am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit. The investigation was conducted by the Department which consisted of reviews of the medical records and interviews with facility management and staff. The complaint alleges that resident sustained pressure injuries while in care. Based on the investigation, it was revealed that resident (R1) had a pressure wound when moved in. Report continued on 9099-C Unfounded This Department has investigated the allegation noted above and have found that the complaint was UNFOUNDED, meaning that the allegations was false, could not have happened and/or was without a reasonable basis. Exit interview was conducted with Administrator Unaisi Waqalala and a copy of the report was provided. Additionally, a Department staff was provided entry in the facility by R2 and was later observed R2 left the facility unattended on 3/11/2022. Furthermore, it was learned that resident R1 was accepted for care with a prohibited health condition, stage 3 pressure injury. R1 has a pressure wound when moved in. As a result of this investigation, the Department finds the allegations above to be substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. On 4/12/2022, the issuance of an Enhanced Civil Penalty was still being determined, however the Department informed the facility Administrator that a civil penalty may be assessed. Exit interview conducted with Administrator Unaisi Waqalala. A copy of this report, LIC 9099-D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 12, 2022 · control 27-AS-20211228152000

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Apr 13, 2022

Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed... The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by Based on interviews and observations, the Licensee did not ensure that hospice care plan is being followed. Staff did not follow hospice nurse instructions to keep R1 clean and dry and apply barrier cream. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Licensee shall submit a plan of correction detailing how the hospice care plan will be follow by POC due date of 4/13/2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 19, 2022

Basic Services. Basic services shall at a minimum include: Care and supervision. This requirement is not met as evidenced by Based on interviews and observations, the Licensee did not ensure resident's hygiene needs are met. Resident R1 was found covered in feces and urine multiple times. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Licensee and LPA agree to: Submit a plan on how the facility will ensure that residents' hygiene needs are met by POC due date 4/19/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 13, 2022

Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidence by: Based on records and observations, the licensee did not ensure an adequate number of staff working in the care facility. Resident R2 was observed leaving the facility unattended on 3/11/2022. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Licensee will ensure that the facility is adequately staffed at all times to meet the resident’s needs. Licensee will submit a plan to include updating LIC 500 personnel report to ensure facility is adequately staffed to be submitted by 4/13/2022. LIC 500 must be accurate and meet all labor requirements.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Apr 13, 2022

Administrator - Qualifications and Duties. The administrator shall have the qualifications...knowledge and ability to conform to applicable laws and regulations. This requirement is not met as evidence by: Based on records and observations, the licensee/administrator did not follow the requirement when admitting new resident. The facility admitted R1 with a pressure wound without knowledge or plan for care. This posed an immediate health and safety risk to resident’s in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Administrator agrees to take training including but not limited to the following: Title 22 regulations, effective communication and record keeping and documentation. Training topics and dates shall be submitted by POC date, 4/13/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Apr 22, 2022

Pre-Admission Appraisal - General. Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs This requirement is not met as evidence by: Based on interview and record review, the licensee did not ensure a pre-admission appraisal was completed for R1 prior to R1s admission. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: The Licensee shall review residents' files to ensure each residents has a pre-admission appraisal on file and any future placement that a pre-admission appraisal is conducted. The Licensee shall provide the Department a plan on how the pre-addmission appraisal is conducted. POC due date of 4/22/2022.

Type of visit: Case Management - Other

A case management visit was conducted today by Tung Truong, Licensing Program Analyst (LPA). LPA met with the Administrator, Unaisi Waqalala. The purpose of the case management visit was to follow up on concerns found during a separate complaint investigation. It was learned through interviews that on multiple occasions, staff #1 (S1) did not have a mask on while working in the facility. It was also learned that visitors were not wearing masks while visiting the facility. The following deficiencies are cited. See LIC 809 D. Appeal rights provided.the state’s words, verbatim · CDSS document, Apr 12, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 13, 2022

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 be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidence by: Based on observation and interviews, the licensee did not ensure that residents are accorded safe and healthful accommodations. Staff S1 did not have a mask on while working in the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Administrator and LPA agree to: Submit letter stating knowledge of, understanding of regulation 87468.1(a)(2) by POC due date 4/13/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87208(a)(12) · Plan of correction due date: Apr 13, 2022

Plan of Operation. Each facility shall have and maintain a current, written definitive plan of operation. The Infection Control Plan. This requirement is not met as evidence by: Based on observation and interviews, the licensee did not ensure the Infection control Plan is being followed. The facility did not follow mitigation plan as evidenced by staff and facility visitors not wearing their masks in the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Administrator and LPA agree to: Submit letter stating knowledge of, understanding of regulation 87208(a)(12) by POC due date 4/13/2022.

Type of visit: Office

An office meeting was held on 4/7/22 at 10am on a Microsoft Teams Meeting video conferencing system review the stipulation adopted on 4/4/2022 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period. The following were in attendance: Regional Manager Krystall Moore, Licensing Program Manager(s)Stephenie Doub, Liza King, Licensing Program Analyst(s) Victoria Brown, Christina Valero, Jamie Ivey Canady, Christopher Hopkins, Representatives of Love and Serenity LLC, Love and Serenity IV LLC, Love and Serenity Elk Grove LLC, Love and Peace LLC, and Abounding Love LLC, Administrators and Licensees of Love and Serenity, Love and Serenity of Elk Grove II, Love and Serenity of Vintage Park, Love and Serenity IV, Love and Serenity Elk Grove, Love and Peace Home Care, Love and Peace II Elderly Care, Abounding Love Home Care, Love and Serenity II, Javier Castro, Ratu “Pio” Vunimatana, Mike Her, Anthony Camacho, Deborah Saunikalou, Julie Nonu, and Bianca Castro. Krystall Moore discussed the purpose and elements of this type of meeting. The Stipulation was reviewed with Representatives, Administrators, and Licensees who expressed their understanding. Items discussed at the meeting included, but not limited to: Stipulation contents · Findings · Revocation of Licenses and Administrator Certificates/License Application Denials – Not Stayed · Exclusions- Not Stayed · Revocations of Licenses and Administrator Certificates/License Application Denials -Stayed with Probation · Stay of Revocation of Licenses and Administrator Certificate and Exclusion to Facilitate Sale of Facilities · Future Application for License, Registration, Certification or Approval · Licensure, Certification or Approval; Application Denial, Tolling of Probationary Period · Completion of Probation · Violation of Stipulation Term · Department's Authority · Monitoring Fee · Waiver of Hearing Rights; Waiver of Appeal/Modification Rights/Waiver of Claims · Severable terms · Public Records · Signatures · Counterparts · Effective Date: (4/4/2022 – 4/4/2025) · No Oral Modification · Closure intent of Love and Serenity LLC dba Love and Serenity · Update on Love and Serenity III regarding owner selling the property The Licensees/Respondents/Representatives stated they would abide by the following: · Abide by the contents/terms of the Stipulation (submit all documents timely) · Operate the facility in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly. CCLD will do the following: · Increase monitoring Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, Apr 7, 2022

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Case Management visit on 2/24/22 at 10:40 AM. 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. Upon LPAs arrival, Caregiver Susan Masiwala was present at facility and contacted Administrator Unaisi Waqalala who arrived a bit later. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit. LPA toured and inspected the physical plant to ensure there are no safety hazards to residents. The purpose of today’s visit is to ensure the instructions provided in the Health and Safety Code Section 1569.38 are being followed according to the accusation. A notice regarding the accusation shall be posted in a conspicuous location advising that an action is pending. LPA observed 4 residents and 1 caregiver during this visit. The temperature inside the facility was observed to be at 70 degrees Fahrenheit which is within the required range of 68-85 degrees Fahrenheit. The hot water temperature was observed to be 105.8 degrees Fahrenheit. LPA observed 2-day perishables and 7-day non-perishables. LPA observed knives and toxins to be 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. 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, Feb 24, 2022

Type of visit: Required - 1 Year

On 1/25/2022 at 9:00 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 staff, who confirmed no residents or staff have had any symptoms of COVID-19 in the last 10 days. Upon LPAs arrival, Caregiver Susan Masiwala was present at facility and contacted Administrator Unaisi Waqalala who arrived a bit later. LPA met with Administrator Unaisi Waqalala explained the purpose of the visit. Administrator holds current certification #6056441740 and expires on 7/08/2022. The facility is licensed to serve up to (6) six non-ambulatory residents. Approved hospice waiver for (2) two. There are currently 5 residents who reside at this facility. LPA toured the facility with Caregiver Susan Masiwala on 1/25/2022 at 9:20 am. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry rooms 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. Hot water measured in the kitchen sink was 124 degrees Fahrenheit and resident’s bathroom sink was 130 degrees Fahrenheit which were not within the required range of 105-120 degrees Fahrenheit. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. 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 clients. LPA also conducted the infection control domain tool. The facility mitigation plan was submitted to CCLD, and it was approved on 5/16/2021. 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, deficiencies were cited on 809-D. An exit interview was held, a copy of this report 809-D and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 25, 2022

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Case Management visit on 11/8/21 at 1:20 PM. LPA met with Anthony Camacho, Staff and stated the purpose of today’s visit. LPA spoke with Unaisi Waqalala, Administrator stating LPA presence at the facility. Unaisi informed LPA that the noticed was sent to the (LTCO), residents and their responsible party. LPA toured and inspected the physical plant with Anthony to ensure there are no safety hazards to residents. The purpose of today’s visit is to ensure the instructions provided in the Health and Safety Code Section 1569.38 are being followed according to the accusation. The instructions include, but not limited to, the requirement to notify the residents and Local Ombudsman (LTCO) within 10 days and to post a notice in a conspicuous location advising that an action is pending. The accusation was served on 10/6/21. Licensee was previously informed that CCL shall receive copies of the notifications to all residents and/or responsible parties and that civil penalties could be assessed if licensee fails to follow the requirements. LPA has received a copy of the notifications and observed the posting of the accusation, and the (LTCO) was called and letter was sent. During the visit, LPA Truong observed the noticed and accusation was posted in a conspicuous location. The noticed and accusation was posted near the entrance of the facility along with all other licensing and CCL required documents. LPA Truong obtained a copy of the noticed that two residents have signed. 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, Nov 8, 2021

Type of visit: POC

On 10/14/2021 at 11:00 am, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a POC visit in regard to deficiencies cited on complaint CONTROL NUMBER 27-AS-20210819122759 and Control Number 27-AS-20210819120128 that were not cleared. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Administrator Unaisi Waqalala. LPA met with facility staff Anthony Camacho and explained the purpose of today’s visit. The purpose of today’s visit is to clear the remaining deficiencies on the complaints below. The remaining deficiencies for complaint CONTROL NUMBER 27-AS-20210819122759 *Deficiency cited under Title 22 Regulation 87411(c) – Cleared. Proof of correction was submitted on 10/13/2021. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days from 9/28/21 - 10/1/21 is total $400.00. Civil penalty in the amount of $400 was issued on 10/1/2021. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued on 10/8/2021. Civil Penalty for five days at $100.00 per day for five days from 10/9/21 - 10/13/21 is total $500.00. Civil penalty in the amount of $500 was issued on today’s visit. Report continued on 809-C *Deficiency cited under Title 22 Regulation 87211(a)(2) – Cleared. Proof of correction was submitted on 10/13/2021. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days from 9/28/21 - 10/1/21 is total $400.00. Civil penalty in the amount of $400 was issued on 10/1/2021. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued on 10/8/2021. Civil Penalty for five days at $100.00 per day for five days from 10/9/21 - 10/13/21 is total $500.00. Civil penalty in the amount of $500 was issued on today’s visit. The remaining deficiencies for complaint Control Number 27-AS-20210819120128 *Deficiency cited under Title 22 Regulation 87468(a)(1) – Cleared. Proof of correction was submitted on 10/13/2021. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days from 9/28/21 - 10/1/21 is total $400.00. Civil penalty in the amount of $400 was issued on 10/1/2021. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued on 10/8/2021. Civil Penalty for five days at $100.00 per day for five days from 10/9/21 - 10/13/21 is total $500.00. Civil penalty in the amount of $500 was issued on today’s visit. Total civil penalties issued $1500. Exit interview was held with Anthony Camacho, a copy of this report, LIC 421FCs, letter of deficiency citations cleared and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 14, 2021

Type of visit: POC

On 10/8/2021, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a POC visit in regard to deficiencies cited on a case management visit on 10/1/2021 and deficiencies for complaint CONTROL NUMBER 27-AS-20210819122759 and Control Number 27-AS-20210819120128 that were not cleared. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Unaisi Waqalala who arrived a bit later. LPA met with facility staff Unaisi Waqalala and explained the purpose of the visit. The following deficiencies were cited a case management visit on 10/1/2021. *Deficiency cited under Title 22 Regulation 87411(a) – Cleared. The facility did not submitted proof of correction by due date. Proof of correction was submitted on 10/6/21. Civil Penalty for two days at $100.00 per day for two days is total $200.00. Civil penalty in the amount of $200 was issued. *Deficiency cited under Title 22 Regulation 87405(a) – Cleared. The facility did not submitted proof of correction by due date. Proof of correction was submitted on 10/6/21. Civil Penalty for two days at $100.00 per day for two days is total $200.00. In addition, a civil penalty of $250 is assessed for repeated violation. Civil penalty in the amount of $450 was issued. Report continued on 809-C The following deficiencies were cited under complaint CONTROL NUMBER 27-AS-20210819122759 *Deficiency cited under Title 22 Regulation 87411(c) – Not cleared. The civil penalty of $400 was issued on 10/1/2021. At this time the facility has not submitted proof of correction of training registration for staff. Civil penalty is $100.00 per day until verified. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued. *Deficiency cited under Title 22 Regulation 87633(d) - Cleared. The civil penalty of $400 was issued on 10/1/2021. Proof of correction was submitted on 10/6/2021. Civil penalty is $100.00 per day until verified. Civil Penalty for five days at $100.00 per day for five days from 10/2/21 - 10/8/21 is total $500.00. Civil penalty in the amount of $500 was issued. *Deficiency cited under Title 22 Regulation 87211(a)(2) – Not cleared. The civil penalty of $400 was issued on 10/1/2021. At this time the facility has not submitted proof of correction. Civil penalty is $100.00 per day until verified. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued. The following deficiencies were cited under complaint Control Number 27-AS-20210819120128 *Deficiency cited under Title 22 Regulation 87468(a)(1) – Not cleared. The civil penalty of $400 was issued on 10/1/2021. At this time the facility has not submitted proof of correction of training registration for staff. Civil penalty is $100.00 per day until verified. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued. Report continued on 809-C Total civil penalties issued $3,050. An exit interview was held, a copy of this report, LIC 421FCs and appeal rights were provided to Unaisi Waqalala.the state’s words, verbatim · CDSS document, Oct 8, 2021

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a case management visit regarding the complaint control # 27-AS-20210819120128. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Administrator, Anthony Camacho who arrived a bit later. LPA met with Administrator Anthony Camacho and explained the purpose of the visit. On complaint control # 27-AS-20210819120128, the allegation: Resident wandered away from the facility was substantiated but was not cited on the complaint's LIC 9099-D. The deficiency for the allegation above is cited on today’s case management visit on LIC 809-D. In addition, 87411(a) Personnel Requirements - General was previously cited on 9/17/2021, therefore, a civil penalty shall be assessed in the amount of $250 for a repeat violation within a 12- month period during this visit. In addition, LPA is reciting the facility for 87405(a) Administrator - Qualifications and Duties. The facility did not provide the Department with proof of administrator certificate for Designated Administrator, Anthony Camacho. A valid administrator certificate is required in order to update the facility profile on Licensing system. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited during this visit. An exit interview was held and a copy of this report, LIC 809-D, LIC 421FC and appeal rights was provided to Administrator Anthony Camacho.the state’s words, verbatim · CDSS document, Oct 1, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 4, 2021

87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on records and LPA’s observation, the facility did not have an adequate number of staff working in the care facility. The facility has multiple incidents of residents’ AWOL from the facility. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2021

Plan of correction: Licensee will ensure that the facility is adequately staffed at all times to meet the resident’s needs. Licensee will submit update LIC 500 personnel report to ensure facility is adequately staffed to be submitted by 10/4/2021. LIC 500 must be accurate and meet all labor requirements. Licensee shall provide CCL with a written declaration stating that he/she has read and understands the Title 22 Regulations by 10/4/2021.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Oct 4, 2021

87405(a) Administrator – Qualifications and Duties. All facilities shall have a certified administrator with enough freedom from other responsibilities and a sufficient number of hours on the premises to give adequate attention to the administration of the facility. This requirement is not met as evidenced by: Based reviewed record, the facility did not provide the Department with a valid administrator certificate for designated administrator, Anthony Camacho. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2021

Plan of correction: The Licensee shall provide the Department with the Administrator Certificate for the Designated Administrator, Anthony Camacho by COB 10/4/2021.

Type of visit: POC

On 10/1/2021, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a POC visit in regard to deficiencies cited on 9/24/2021 for complaint CONTROL NUMBER 27-AS-20210819122759 and Control Number 27-AS-20210819120128. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Administrator, Anthony Camacho who arrived a bit later. LPA met with Administrator Anthony Camacho and explained the purpose of the visit. The following deficiencies were cited under complaint CONTROL NUMBER 27-AS-20210819122759 *Deficiency cited under Title 22 Regulation 87411(c) - not cleared. The facility has not submitted proof of correction. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days is total $400.00. Civil penalty in the amount of $400 was issued. *Deficiency cited under Title 22 Regulation 87633(d) - not cleared. The facility has not submitted proof of correction. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days is total $400.00. Civil penalty in the amount of $400 was issued. Report continued on 809-C *Deficiency cited under Title 22 Regulation 87211(a)(2) - not cleared. The facility has not submitted proof of correction. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days is total $400.00. Civil penalty in the amount of $400 was issued. The following deficiencies were cited under complaint Control Number 27-AS-20210819120128 *Deficiency cited under Title 22 Regulation 87468(a)(1) - not cleared. The facility has not submitted proof of correction. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days is total $400.00. Civil penalty in the amount of $400 was issued. *Deficiency cited under Title 22 Regulation 872(a)(1)(D) - cleared. Licensee complied with the terms of the POC by POC due date. Total civil penalties issued $1,600. Exit interview conducted with Administrator Anthony Cacacho, a copy of this report, LIC 421FCs and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 1, 2021

Allegation investigated: Staff not supervising resident resulting in multiple falls and injuries Residents bed alarm was not in on position and unplugged by staff Facility failed to report injury

On 09/24/2021 at 3:00 PM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to deliver a complaint findings. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Administrator, Anthony Camacho who arrived a bit later. LPA met with Administrator Anthony Camacho and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. The investigation revealed that resident (R4) has fallen multiple time resulting in bruising on the legs. R4 also sustained a bump on the forehead due to a fall. The facility was informed by hospice agency (Dignity Health Hospice) to report R4’s falls; however, the facility did not report to R4’s agency as required. In addition, Dignity Health Hospice had provided R4 with bed alarms. The alarm will sound off when R4 attempts to get out of bed. It was observed by hospice nurse on 8/18/2021 that R4’s alarm was on the ground and disengaged. On 8/27/2021, during an inspection, LPA Truong observed the battery was unplugged from the alarm. Furthermore, the facility failed report injuries to Dignity Health Hospice and Licensing as required. Report continued on 9099-C Substantiated As a result of this investigation, the Department finds the allegations above to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6 and/or Health and Safety Code. Exit interview was conducted with Administrator Anthony Camacho, a copy of the report, LIC 9099-D and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 24, 2021 · control 27-AS-20210819122759

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c) · Plan of correction due date: Sep 27, 2021

Personnel Requirements – General. Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs. The requirement is not met as evidenced by: Based on interviews and records reviewed, the Licensee did not provide adequate supervision to resident. Resident (R4) has sustained injuries from multiple falls due to bed alarms were not engaged. This poses an imminent health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2021

Plan of correction: The Licensee shall sign up for training through CCL approved vendor list on the care and supervision responsibilities. The Licensee shall send CCL proof of registration for training for all staff by COB 9/27/2021. Upon completion of the training the facility will send to LPA proof of completion, list of staff attendees with their signatures with an acknowledgment of understanding and compliance with this regulation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(d) · Plan of correction due date: Sep 27, 2021

Hospice Care of Terminally Ill Residents. The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times. This requirement is not met as evidenced by: Based on interviews and records reviewed, the facility did not follow the hospice care plan which require R4 to have bed alarm on. Resident R4 alarms was not on as required. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2021

Plan of correction: Licensee/Administrator shall ensure hospice care plan are follow at all time. Provide CCL with a written declaration stating that he/she has read and understands the Title 22 Regulations by 9/27/2021.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Sep 27, 2021

Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following . . . Any incident which threatens the welfare, safety or health of any resident . . . This requirement is not met as evidenced by: Based on interviews and records reviewed, the Licensee/Administrator did not report the incident to the Community Care Licensing Division (CCLD) as required by Title 22. Resident R4 had multiples falls resulting in injuries that was not reported to Licensing and hospice agency. This poses an imminent health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2021

Plan of correction: Administrator agrees to take training including but not limited to the following: Title 22 regulations, effective communication and record keeping and documentation. Training topics and dates shall be submitted by POC date, 09/27/2021.

Allegation investigated: Resident wandered away from the facility Staff handled resident in a rough manner Facility failed to report AWOL Facility failed to report incidents to the Department

This is an amended document to indicate the citation for substantiated allegation: Resident wandered away from the facilty is missing on the 9099-D. This deficientcy is cited on a case management visit (LIC 809-D) on 10/1/2021. On 09/24/2021 at 3:00 PM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to deliver a complaint findings. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Administrator, Anthony Camacho who arrived a bit later. LPA met with Administrator Anthony Camacho and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. The investigation revealed that resident (R1) had AWOL'ed from the facility on 8/16/2021 and on another occasion about 3 weeks prior. R1 is conserved and has dementia. R1's LIC 602 Physician Report indicated that R1 was not allowed to leave the facility unassisted. On one occasion, neighbor found R1 wandering on the street and assisted R1 back to the facility. On 8/16/2021, neighbor found R1 on laying on the sidewalk in distress and notified facility staff to assist R1 back to the facility. During this incident, staff was observed to handled R1 in a rough manner when assisting R1 up from the ground. In addition, the administrator admitted that R1's AWOLs was not reported to Licensing. Reviewed of records reveiled that there were no incident reports submitted regarding the incidents. Report continued on 9099-C Substantiated As a result of this investigation, the Department finds the allegations above to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6 and/or Health and Safety Code. Deficiency regarding facility failed to report incidents was cited on LIC 9099-D of Complaint Control # 27-AS-20210819122759 Exit interview was conducted with Administrator Anthony Camacho, a copy of the report, LIC 9099-D and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 24, 2021 · control 27-AS-20210819120128

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a)(1) · Plan of correction due date: Sep 27, 2021

Personal Rights. Each resident shall be accorded dignity in his/her personal relationships with staff, residents and other persons; shall be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature; and shall be accorded safe, healthful and comfortable accommodations, This requirement is not met as evidenced by: Based on the investigation, the Licensee/Administrator did not ensure resident is treated with respect and accorded with dignity. On 8/16/2021, facility staff handled resident R4 in a rough manner when assisting R4 up from the ground which was observed by a bystander. This poses an imminent, Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2021

Plan of correction: The adminsitrator shall schedule an in-service training for staff on personal rights, roles and responsibilities, that shall be completed by 9/27/2021. Also, a plan shall be developed and implemented by the facility outlining how residents personal rights will not be violated again in the future. Send proof of corrections in to CCL upon completion. The licensee shall provide proof of classes (date and time), who attended, to include signatures of staff that attended by POC due date 9/27/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 1, 2021

Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on interviews and records reviewed, R1 AWOL'd from the facility on 08/16/21. Per R1's LIC602 physician report, R1 is unable to leave unassisted. The facility failed to submit an unusual incident report for R1's AWOL which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 24, 2021

Plan of correction: The Administrator shall submit a plan to CCL on how the facility will ensure that any and all unauthorized absences (AWOLs) are reported to all required parties/entities including CCL. POC shall be submitted by POC date, 10/1/21.

Type of visit: POC

On 9/21/2021 at 9:50am, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Proof of Correction (POC) Visit. LPA met with Administrator Anthony Camacho and explained the purpose of today’s visit. LPA reviewed document submitted for plans of correction observed that the deficiencies cited on 09/17/2021 have been cleared. *Deficiency cited under Title 22 Regulation 87411(a) and 87405(a) has been cleared. Licensee complied with the terms of the POC by POC due date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 21, 2021

Type of visit: POC

On 09/17/2021 at 1:30 PM, Licensing Program Analyst (LPA) Tung Truong conducted a plan of correction (POC) visit in relation to a citation issued on 9/2/2021. LPA met with Assistant Administrator Una Waqalala and explained the purpose of the visit. Proof of correction was submitted to LPA Truong via email on 9/13/2021 by Administrator Anthony Camacho. The files attached to the email was corrupted and was not readable. *Deficiency cited under Title 22 Regulation 87411(a) and 87405(a) are extended to 9/20/21. Citation issued on 9/2/2021 will be recited on today's visit on the LIC809-D. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809-D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. Exit interview held with Assistant Administrator Una Waqalala , a copy of the report and LIC809-D was provided.the state’s words, verbatim · CDSS document, Sep 17, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 20, 2021

87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on records and LPA’s observation, the facility did not have an adequate number of staff working in the care facility. The facility has multiple incidents of residents’ AWOL from the facility. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2021

Plan of correction: Licensee will ensure that the facility is adequately staffed at all times to meet the resident’s needs. Licensee will submit updated LIC 500 personnel report to ensure facility is adequately staffed to be submitted by 9/20/2021. LIC 500 must be accurate and meet all labor requirements.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Sep 20, 2021

87405(a) Administrator – Qualifications and Duties. All facilities shall have a certified administrator with enough freedom from other responsibilities and a sufficient number of hours on the premises to give adequate attention to the administration of the facility. This requirement is not met as evidenced by: Based on records and LPA’s observation, the facility did not have adequate Administrator oversight. During LPA's visit, no Licensee/ administrator in facility was present in the facility to assist LPA with the visit. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2021

Plan of correction: Licensee shall devise a plan in writing and submit it to Licensing by close of business 9/20/21.

Allegation investigated: Not enough staff to meet resident's needs

On 09/2/2021 at 8:50 AM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to deliver a complaint finding. Upon LPAs arrival, caregiver Tawnya Dunaway was present at facility and contacted Administrator, Anthony Camacho who arrived a bit later. LPA met with Administrator Anthony Camacho and explained the purpose of the visit. Based on information gathered and LPA’s observation, the facility is not adequately staffed at all times to meet the resident’s needs. During LPA’s previous visit on 8/27/21, there is only one staff present at the facility. Upon LPA’s arrival resident (R3) opened the front door and greeted LPA. Staff (S1) was busy tending another resident’s needs and was not able to assist LPA. In addition, the facility had multiple incidents of residents’ AWOL from the facility. Report continued on 9099-C Substantiated As a result of this investigation, LPA finds the allegation above to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited on 9099-D of complaint control number 27-AS-20210901140049. Complaint date 9/1/2021. Exit interview was conducted with Administrator Anthony Camacho, a copy of the report, LIC 9099-D and appeal rights were provided. This Department has investigated the allegations noted above and have found that the complaint was UNFOUNDED, meaning that the allegations was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint. Exit interview was conducted with Administrator Anthony Camacho, a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 2, 2021 · control 27-AS-20210823113613

Allegation investigated: Resident was found by paramedics outside on the sidewalk. There is no administrator oversight at the faciilty; no one is responding to phone calls or returning messages from the public.

On 09/2/2021 at 8:50 AM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to commence a complaint investigation. Upon LPAs arrival, caregiver Tawnya Dunaway was present at facility and contacted Administrator, Anthony Camacho who arrived a bit later. LPA met with Administrator Anthony Camacho and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. The investigation revealed that on 8-31-2021 resident R2 was found on the street by paramedics and brought to Kaiser Hospital for evaluation. R2 has dementia and AWOL from the facility unassisted. R2 was conserved and is not allowed to leave the facility unassisted. Report continued on 9099-C Substantiated The complaint also alleges that there is no administrator oversight at the facility; no one is responding to phone calls or returning messages from the public. Based on information gathered and LPA’s observation, the phone line was not in service during the time of the incident. LPA attempted to call the facility several times and the call went straight to voicemail. During the last two visits at the facility, the administer was not present at the facility to assist LPA. As a result of this investigation, LPA finds the allegations above to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6 and/or Health and Safety Code. Exit interview was conducted with Administrator Anthony Camacho, a copy of the report, LIC 9099-D and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 2, 2021 · control 27-AS-20210901140049

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 3, 2021

87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on records and LPA’s observation, the facility does not have an adequate number of staff working in the care facility. The facility has multiple incidents of residents’ AWOL from the facility. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee will ensure that the facility is adequately staffed at all times to meet the resident’s needs. Licensee will Submit update LIC 500 personnel report to ensure facility is adequately staffed to be submitted by 9/3/2021. LIC 500 must be accurate and meet all labor requirements.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Sep 3, 2021

87405(a) Administrator – Qualifications and Duties. All facilities shall have a certified administrator with enough freedom from other responsibilities and a sufficient number of hours on the premises to give adequate attention to the administration of the facility. This requirement is not met as evidenced by: Based on observation, during LPA's visit no Licensee/ administrator in facility was present in the facility to assist LPA with the visit.the state’s words, verbatim · CDSS document, Sep 2, 2021

Plan of correction: Licensee shall devise a plan in writing and submit it to Licensing by close of business 9/3/21. Final plan of action shall be completed within 15 days and proof of that correction shall be submitted to Licensing in writing.

Type of visit: Required - 1 Year

On 08/05/2021 at 9:35 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA called to ensure that the facility does not have any positive COVID-19 cases. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Designated Administrator, Anthony Camacho who arrived a bit later. LPA met with Designated Administrator Anthony Camacho and explained the purpose of the visit. Licensee, Javier Castro, holds current certification #6011043740 and expires on 12/12/2021. The facility is licensed to serve up to (6) six non-ambulatory residents. Approved hospice waiver for (2) two. There are currently 6 residents who reside at this facility. LPA toured the facility with Designated Administrator Anthony Camacho on 08/05/2021 at 10:25 am. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, garage, 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 119.5 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. 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 also conducted the infection control domain tool. Continued on 809-C The facility mitigation plan was submitted to CCLD, and it was approved on 5/16/2021. 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) Administrative Organization (LIC309) (7) Control of Property Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview held and a copy of report given.the state’s words, verbatim · CDSS document, Aug 5, 2021