Indocare House 2

Type of visit: Case Management - Deficiencies

On 12/30/22, License Programming Analyst (LPA) Renee Campbell conducted a Case Management visit to issue a citation for findings discovered during a complaint investigation COMPLAINT CONTROL NUMBER: 27-AS-20220909152751. LPA was met by Paul and Teresita Almondehe and explained the purpose of the visit. During the course of the investigation into the above listed complaint number the LPA conducted interviews with staff and clients, in addition the resident file was reviewed. A preplacement appraisal was completed 01/09/2020, interviews revealed that the resident began to wander during the first week of placement, a reappraisal was not completed as required to address the safety concerns until 10/01/2021. 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. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.the state’s words, verbatim · CDSS document, Dec 30, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jan 5, 2023

97463(a) The pre-admission appraisal shall be updated,.. to keep the appraisal accurate......when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first.. This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee did not update the appraisal when the resident began to wander during the first week of placement.the state’s words, verbatim · CDSS document, Dec 30, 2022

Plan of correction: Administrator will audit all resident charts to ensure appraisals are accurate and up to date and they will then read the regulation regarding this citation and write a statement confirming same by POC due date. Both items will be emailed to renee.campbell@dss.ca.gov

Allegation investigated: Lack of supervision resulting in resident being outside unattended Unexplained Black Eye

On 12/02/22, License Programming Analyst (LPA) Renee Campbell made an unannounced visit to the Indocare 2 Facility at approximately 9:00 am. LPA was met by the Administrator and staff and explained the purpose of the visit. Employee timesheets from August and September of 2022 and the Personnel Report were reviewed. Review of R1’s 602 documented sundowning behaviors, the preplacement appraisal documents night supervision required. LPA reviewed the staffing schedule from August 2022, September 2022 and interviewed staff and the Administrator. The work schedule for all staff revealed there are no awake staff scheduled from 10 pm to 6 am. During that time, “staff are asleep and will only wake up if there is an emergency”, per the Administrator during an interview. S2 reported that she works in the facility most days. LPA asked if she had been present when R1 had wandered. S2 stated “Yes”. S2 explained that since staff were not awake at night, and would not have seen her get up or go out the door at night. LPA asked S2 if she had seen R1 get the black eye. S2 described finding blood in the bathroom one morning and a spot of blood on R1’s bed. S2 saw the black eye but no one witnessed how R1 got the black eye. Based on LPAs observations, interviews, and record reviews, there is a preponderance of evidence to conclude that the facility does not have awake staff during sleeping hours as required and that R1 sustained unexplained injuries while in care due to lack of appropriate monitoring, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given. Substantiatedthe state’s words, verbatim · CDSS document, Dec 2, 2022 · control 27-AS-20220909152751

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.321(e) · Plan of correction due date: Dec 16, 2022

1569.321(e) Every facility...shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety and well-being. Based on interviews and record reviews, the licensee did not meet the supervision needs of clients. This poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 2, 2022

Plan of correction: Licensee will audit all resident charts and current staffing schedules to ensure adequate monitoring and supervision of resident . Licensee will submit an audit to be completed by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(4) · Plan of correction due date: Dec 16, 2022

87705(b) Care of Persons with Dementia (b) Licensees who retain residents with dementia ... shall have at least one night staff person awake and on duty if any resident with dementia is determined ... to require awake night supervision. Based on interviews and record reviews, the licensee did not meet the supervision needs of dementia clients in need. This poses a potential Health, Safety or Personal Rights risk to person in care.the state’s words, verbatim · CDSS document, Dec 2, 2022

Plan of correction: The Administrator and Licensee will read the regulation regarding this citation and write a statement that the regulation was read and understood. The Administrator shall email the statement to renee.campbell@dss.ca.gov by the close of business of the POC date.

Allegation investigated: Facility failed to report changes to Responsible Party

This is an amended report to correct the time listed above. LPA was at the facility from 9 am to 4 pm. On 12/02/22, License Programming Analyst (LPA) Renee Campbell made an unannounced visit to the Indocare 2 Facility at approximately 9 am. LPA was met by Luisito Manalansan and Orpha Manalansan and later Lomendehe and explained the purpose of the visit to conduct an annual inspection and case management. LPA conducted interviews with staff and clients. Incident Reports, care notes, hospital records and 602 were reviewed. There were five incidents of the client wandering that were recorded over a two year period and the client’s daughter or responsible party (RP) was notified each time. There were no other caregiver notes or incidents reports to confirm if there were any unreported events and the RP could not be reached to discuss the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the allegation is UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 2, 2022 · control 27-AS-20220909152751

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Renee Campbell arrived unannounced to conduct an Annual Required inspection on this date. LPAs inspected the facility, which included but not limited to the bathrooms, kitchen, living room and the outside area of the facility. LPAs observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. There is a comfortable room temperature of 73 degrees Fahrenheit for clients in care. Grab bars and non-skid mats were observed in bathrooms and throughout the facility. Food supply was stored and prepared in a healthful manner. Clients received Breakfast, snacks and a hot lunch. The hot water temperature in the client's bathroom measured 110 degrees Fahrenheit. All observed toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed. Carbon monoxide and smoke detectors found to be in working order. Centrally stored medications, toxins and sharp objects were locked and inaccessible to clients. Staff members have a current first aid kit and CPR. First aid kit was checked and is complete and disaster drill is current. No deficiencies were cited during this annual inspection. Exit interview conducted. Report provided.the state’s words, verbatim · CDSS document, Dec 2, 2022

Type of visit: Required - 1 Year

On 09/22/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required infection control inspection. At approximately 2:40 PM, LPA met with the Main Caregiver Orpha Manalansan at the front door of the facility. LPA explained the purpose of the Infection Control visit. At approximately 2:50 PM, LPA Filouane conducted a tour of the facility with the Main Caregiver. The physical plant is consistent with the submitted facility sketch/floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility's kitchen is free of debris. At 2:55 PM, LPA observed the facility's restrooms as clean and equipped with hand washing signage. The facility's backyard was free of debris. The facility's food supply was sufficient. PPE and cleaning supplies are stocked and sufficient. The clients' bedrooms were inspected and all had required lighting and furniture. Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguishers as current. The facility's first aid kit included the required tweezers, scissors, and a thermometer. At approximately 2:55 PM, LPA completed the facility tour for Infection Control with the Main Caregiver. This report was reviewed with the Main Caregiver. No deficiencies were cited today. Exit interview conducted with the Main Caregiver. A copy of this report will be emailed to the Administrator.the state’s words, verbatim · CDSS document, Sep 22, 2021