Skye Luis Care Home

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a quarterly case management visit. LPA Valerio met with Administrator Annie Rodriguez and explained the purpose of the visit. LPA observed the current stipulation order place in a conspicuous place in the front area of the home near the staff desk. LPA and Administrator Annie toured the facility to ensure compliance with Title 22 regulations. LPA observed 4 residents in care. 2 residents were napping, 1 resident was finishing up lunch, and 1 resident was listening to music of their choice. The facility has an approved hospice waiver for 1, and there is currently 1 resident on hospice. Common areas and resident bedrooms were observed to be clean, organized, and free from obstructions. Facility was observed to have emergency water and a fully stocked pantry. Staff working in the home were observed to be fingerprint cleared. Staff have updated 2023 training that align with the stipulation order. LPA reviewed training files for all staff. The licensee/administrator has completed 18 out of 18 hours of training related to observation change in residents, duty to obtain timely medical care, prohibited health conditions and prevention of pressure injuries. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with staff, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 6, 2023

Type of visit: POC

LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual visit conducted on 5/8/2023 . LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiency cited on 5/8/23 has been cleared. Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date. Facility was provided POC cleared letter. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 11, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Marvin and Andres explained the purpose of the visit. Later joined by Monalisa Legaspi. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 142 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees. Fire extinguishers and Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medications. LPA reviewed 2 resident and 3 staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. During the file review LPA observed outdated physician's report for R1 (2019). R1 has a diagnosis of Dementia. First aid kit was checked and is complete. LPA observed a carbon monoxide detectors in the facility. Fire drill was conducted on 12/2022. All deficiencies are cited from the California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8 ; and the Health and Safety Code 1569.38 Residential Care Facilities on the LIC 809-D. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. Appeal Rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, May 8, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80088(e)(1) · Plan of correction due date: May 9, 2023

Furniture, Fixtures, Equipment, and Supplies 1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).... LPA tested hot water at 142 degrees F. Licensee failed to assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, May 8, 2023

Plan of correction: Staff lowered the thermostat during the tour and agreed to test the hot water for 3 days. Test hot water in the bathroom to meet Title 22 regulations. Send 3 day hot water temperature to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: May 19, 2023

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Based on observation, interview, and records reviewed, the licensee did not comply with the section cited above in (1) out of (1) residents diagnosed with dementia which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2023

Plan of correction: Licensee agrees to submit a plan of correction to LPA by 5/19/2023 on how R1's annual appraisal will be completed.

Allegation investigated: Facility staff handled resident in a rough manner. Facility staff sexually abused resident while in care.

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to deliver complaint investigation findings. LPA met with facility staff, and explained the purpose of the visit. The department interviewed resident 1's responsible parties. All 3 individuals do not believe the allegations are true. R1 has advanced Dementia and is known to say things that do not occur. According to Elk Grove Police records, EGPD conducted a investigation and concluded unfounded. The case was closed due to lack of evidence. According to medical records, resident 1 was taken to the hospital due to facility staff notifying blood in R1s stool during a diaper change. Medical records show two diagnosis with one having symptoms including delusions. According to interviews with social worker and responsible party, resident makes frequent similar accusations day to day and rescinds those accusations. R1 was discharged back to Skye Luis Care Home. Based on evidenced and statements gathered, there is no evidence to show that the allegations were true. The allegations are unfounded. An exit interview was held with Administrator Annie via cell, and a copy of the report was provided to facility staff at the facility. Unfoundedthe state’s words, verbatim · CDSS document, Mar 9, 2023 · control 27-AS-20230213093535

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a quarterly case management visit. LPA Valerio met with facility staff and explained the purpose of the visit. LPA toured the facility to ensure compliance with Title 22 regulations. LPA observed the current stipulation order place in a conspicuous place in the front area of the home. LPA reviewed training files for all staff. The licensee/administrator has completed 18 out of 18 hours of training related to observation change in residents, duty to obtain timely medical care, prohibited health conditions and prevention of pressure injuries. All staff working in the home were observed to be fingerprint cleared. Staff have updated 2022 training that align with the stipulation order. LPA observed 3 residents and 2 staff members. 1 resident was on an outing during the visit. 1 resident was going through paperwork, 1 resident was watching television and on their computer, and another resident was engaging with the staff. The home was observed to be clean, organized, and free from obstructions. Facility had a 30-day supply of PPE and fully stocked fridge and pantry with non-perishables and perishables. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with staff, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Dec 29, 2022

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a quarterly health and safety case management visit. LPA Valerio met with facility staff and explained the purpose of the visit. Staff confirmed there are 0 residents or staff that have displayed any signs or symptoms of COVID-19 in the last 10 days. Administrator Annie was called via phone by staff. Administrator gave staff permission to sign on her behalf. LPA observed the current stipulation order place in a conspicuous place in the front area of the home. LPA reviewed training files for all staff. The licensee/administrator has completed 18 out of 18 hours of training related to observation change in residents, duty to obtain timely medical care, prohibited health conditions and prevention of pressure injuries. All staff working in the home were observed to be fingerprint cleared. Staff have updated 2022 training that align with the stipulation order. LPA observed 3 residents and 2 staff during the visit. Two residents were in the living room and one in their room. LPA observed staff interactions with residents to be friendly and supportive. Residents were observed to be cheerful and relaxed. The home was observed to be clean, organized, and free from obstructions. Facility had a 30-day supply of PPE and fully stocked fridge and pantry with non-perishables and perishables. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Aug 8, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a required 1-year annual. LPA Valerio confirmed there are 0 residents or staff that have displayed any signs or symptoms of COVID-19 in the last 10 days. LPA Valerio met with Administrator/Licensee Annie Lyn Rodriguez and explained the purpose of the visit. LPA Valerio completed the infection domain tool. Facility staff are said to clean multiple times per shift. COVID-19 signs regarding social distancing, hand washing, infection control, and prevention strategies are placed at the front area of the home. LPA Valerio toured the physical plant interior and exterior to ensure compliance with Title 22 regulations. All emergency exits were clear from obstructions. A two-day supply of perishable foods and a seven-day supply of non-perishable foods were observes. An emergency supply of food and water was observed. Medication cabinet, cleaning supplies, and sharps were locked away and inaccessible to residents in care. A first aid kit was observed to be fully stocked with necessary items in the medication cabinet. Hot water was measured at 106.1*F. Room temperature was set to 74*F. All required furniture and furnishings were observed in the resident bedrooms and bathrooms. Fire extinguishers were observed to be charged and within compliance with last check on 03/31/2022. The backyard had a large sitting area for residents and/or visitors. During the visit, staff was observed to care for residents needs and assisting with ADLs. LPA requested facility documentation: LIC 610D, LIC 308, LIC 500, Liability Insurance Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with the Administratorthe state’s words, verbatim · CDSS document, Apr 27, 2022

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

Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license. LPA observed the current stipulation order place in a conspicuous place in the front area of the home. The licensee has completed 10 out of 18 hours of training related to observation change in residents, duty to obtain timely medical care, prohibited health conditions and prevention of pressure injuries. The last training is scheduled to be completed on May 02, 2022. A detailed copy of training course outline and certificates was obtained for the facility file. Licensee was reminded that all unusual incidents must be verbally informed to licensing by the next working day and a written report must be submitted within seven days of the incident. LPA observed zero residents with prohibited health conditions. On 03/18/2022, LPA Valerio received the licensee's written procedures for obtaining timely medical care for residents and for extended absences of the administrator. Licensee stated all staff have been trained and are aware of the procedures. Licensee was reminded to review stipulation order to ensure all requirements are met by their deadlines. During the visit, LPA interacted with residents. Residents were observed watching television and sitting in the front area. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with the Administratorthe state’s words, verbatim · CDSS document, Apr 27, 2022

Type of visit: Office

Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an announced Office visit on 3/8/22 at 1:00pm. This meeting will be held using “Microsoft Teams”. Present in the meeting were Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Stephenie Doub, LPA Victoria Brown, LPA Christina Valerio, LPA Jamie Ivey Canady, representatives of 5M Care LLC and Mariolyn Care LLC: Annie Lyn J Rodriguez, and Monalisa Legaspi. Krystall Moore discussed the purpose and elements of this type of call. It is to review the stipulation adopted on 2/22/2022 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period of 3 years. The Stipulation was reviewed with representatives of 5M Care LLC who expressed their understanding. Items discussed at the meeting included, but not limited to: Stipulation And Waiver; And Order · Findings · Revocations/Denial/Exclusion: STAYED with Probation · Future Application for License, Registration, Certification or Approval · Licensure Certification or Approval · Trustline and Home Care Aide Registries · 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 Record · Signatures · Counterparts · Effective Date: (2/22/2022 – 2/22/2025) · No Oral Modification · Representations Re: Administrator presence The Licensees/Respondents/Representatives stated they would abide by the following: · Abide by the contents/terms of the Stipulation · Operate the facility in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly · Hospice Waivers: Service to only those currently residing in the home(s) CCLD will do the following: · Increase monitoring · Contact the Administrator Certificate Unit regarding the issuance of a certificate to Annie Lyn Rodriguez due to the stipulation agreement Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted via telephone 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, Mar 8, 2022

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christina Valerio arrived on November 19th, 2021 for an unannounced case management to follow up on a substantiated complaint investigation. LPA met with Annie Rodriguez, Representative of 5M Care LLC and stated the purpose of the visit. On April 17, 2020, the Department concluded a complaint investigation which alleged the following: Staff did not seek medical attention in a timely manner; resident (R1) sustained an unstageable pressure injury and unexplained fracture while in care. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87615(a)(1) Prohibited Health Conditions, § 87465(g) Incidental Medical and Dental Care Services. The facility did not seek medical attention timely and also retained R1 for 14 days with an unstageable pressure injury without a hospice referral from a physician nor did they request an exception from the Department. The investigation revealed that on December 6, 2019 the R1, sustained an acute comminuted and displaced proximal left tibial metaphyseal fracture (Left knee fracture) while being transferred with the assistance of staff (S1 and S2). On December 6, 2019, R1’s responsible party went to the facility and observed swelling below the left knee and contacted R1’s Primary Care Physician (PCP). R1’s responsible party and the facility was informed by the PCP, to monitor R1’s knee and see how it looks on December 9, 2019, and in the interim to use a cold compress and pain medication. No other instructions or patient care was advised by the PCP at this time. On December 13, 2019, the facilities Daily Reports indicate that R1 could not move their left leg. The facility did not seek medical attention between December 9, 2019, through December 19, 2019, after seeing increased swelling. Continues on LIC 809-C... ...Continued from LIC 809 On December 20, 2019, the Acting Administrator was called in to observe R1’s leg and had stated the leg looked bad, as there was purple and blue bruising and a pressure sore to the right heel. On December 20, 2019, the facility called 9-1-1 and R1 was brought to the hospital via ambulance from the facility for lower left leg pain. Hospital medical records indicate upon admission, R1 was observed to have left lower leg pain from the knee down, with significant deformity and bruises. X-rays were taken of the left tibia-fibula region, which showed an acute comminuted and displaced proximal tibial fracture. The facility Daily Reports from December 6, 2019 through December 20, 2019 never indicate staff observing any bruises on her left leg, just that R1 had pain in her left leg. Hospital medical records from December 20, 2019, also indicated R1 was admitted to the hospital with unstageable pressure injuries on the right heel and several stage 2 pressure injuries on the coccyx, left heel, left foot outer lateral, left leg, and upper back. The facility’s Daily Reports indicated that staff used Vaseline on R1’s heels and buttock on December 11, 2019 and December 16, 2019. There was no mention in the Daily Reports of any change in the skin integrity of R1. The facility notes do not mention observation of any pressure injuries from December 6, 2019, until R1 was hospitalized. It was determined through an interview with the Acting Administrator on January 15, 2019, that the Acting Administrator observed a pressure sore to the right heel on December 20, 2019. Based on observation, interview, and record review, the licensee did not obtain timely medical attention which resulted in R1 being diagnosed with an acute comminuted and displaced proximal tibial metaphyseal fracture and pressure injuries that required hospitalization, which is a serious bodily injury. The licensee’s failure to seek timely emergent care caused the resident to suffer serious bodily injury. At the time of the complaint visit on April 17, 2020, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. Page 2 of 3 ...Continued from Page 2 of LIC 809 - C The Department has concluded an analysis and has determined that a civil penalty is warranted for the serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” Today November 19th, 2021, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on April 17, 2021 the amount of the civil penalty issued today will be $9,500. A copy of the LIC 421D was given to facility representative Annie Rodriguez and originals were signed. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Annie Rodriguez's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D. Page 3 of 3.the state’s words, verbatim · CDSS document, Nov 19, 2021

Type of visit: Office

On 08/10/21 at 1:00 PM, a Non-Compliance Conference was conducted on this day in the Sacramento South Regional Office via Microsoft Teams, due to COVID 19 precautions. The purpose of this Non-Compliance Conference meeting was to discuss the citations that has been issued in the last 24 months. Present in the meeting was Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Christina Valerio, Licensing Program Analyst (LPA) Victoria Brown, Licensee/Administrator Annie Lyn Rodriguez, Designated Administrator Monalisa Legaspi Silaean, Long Term Ombudsman Sergio Landeros, and Licensee’s Legal Representative from Simas and Associates LTD Ryan Keever. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. 5M CARE HOME, LLC, has been cited four type A deficiencies within the last three years. The facility was cited for the following issues Observation of Clients, Prohibited Health Conditions - Healing Wounds, Admission Agreement, Reporting Requirements, and Incidental Medical and Dental Care Services. Issues discussed during the meeting were: · The complaint filed against this facility since licensure · Incidental Medical and Dental Care Services/Observation of Resident · Prohibited Health Conditions – Healing Wounds · Admission Agreement · Reporting Requirements Continued on LIC 809-C... Page 1 of 2 Continued from LIC 809... The facility has stated they will do the following to achieve continued and substantial compliance: Incidental Medical and Dental Services - Licensee has implemented Daily Skin Integrity Logs. Staff check the resident’s skin two times per day, once in the morning and once at night, note their observations on the log, and sign their name next to the observations on the log. - Licensee has implemented Daily Repositioning Logs. For any residents that require repositioning, facility staff will reposition the resident every two hours, which will be documented and signed by the staff when the act of repositioning the resident occurs. Prohibited Health Conditions - Licensee informed the Department that they will not accept individuals with a stage 3 or 4 wounds, or any hospice residents without an exception. - If current resident develops pressure wounds, the licensee stated they will monitor the wound closely and ensure care is provided according to Physician’s Orders. If the pressure wounds become stage 3 or stage 4 pressure wounds, the licensee will transport the resident to a higher level of care immediately. The licensee will have resident in care unless wounds are no longer a stage 3 or stage 4 or the Department has granted and issued an exception for the resident. Reporting requirement - Licensee stated she reports incidents immediately after the incident occurs Admission Agreement - The licensee has implemented a change to their Admission Agreement and will continue to ensure Admission Agreement is linear with Title 22 Regulations. - The licensee has implemented a Resident Admission Packet Checklist Procedure to ensure the Admission Packet is filled entirely and documents are not missing. Technical Support Program - The licensee has agreed to take part in the Department’s Technical Assistance Program. Page 2 of 3.... Continued from LIC 809- C page 2.... CCLD will do the following: · Increase Monitoring · Technical Support Program Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit. An exit interview was conducted with Administrator Annie Lyn Rodriguez. A copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. Administrator Annie will sign the document and send signed copy to LPA Valerio at christina.valerio@dss.ca.gov. Page 3 of 3.the state’s words, verbatim · CDSS document, Aug 10, 2021