Sunny Peace 1

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 5/19/23 at 1:45pm. Administrator Certificate expires 2/7/2024 for Russel Romero.. LPA met with Emelda Pratt, Caregiver who contacted the Administrator Eufronio Carrasco regarding the purpose of todays visit. Russel Romero, Adm arrived to assist with todays visit. A The facility is licensed for a capacity of 6. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and interviewed a random amount of residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 81*F which is within the required range of 68-85*F. The hot water temperature was measured at 118.4*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 staff and 2 resident files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Facility Responsibility (LIC308) Administrator Certificate-Updated Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, May 19, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 5/16/22 at 1:45pm. Administrator Certificate expires 11/28/2022. LPA met with Emelda Pratt, Caregiver who contacted the Administrator Eufronio Carrasco regarding the purpose of todays visit. Designee Christine Torres arrived within 15 minutes. The facility is licensed for a capacity of 6. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and interviewed a random amount of residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 78*F which is within the required range of 68-85*F. The hot water temperature was measured at 117.4*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Facility Responsibility (LIC308) Administrator Certificate-Updated Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, May 16, 2022

Allegation investigated: Facility failed to issue a refund

Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA Valerio met with Licensee Maria Carrasco, explained the purpose of the visit, and confirmed that staff and residents have not experienced any signs or symptoms of COVID-19 in the last ten days. The investigation was conducted by LPA Valerio and consisted of interviews with Licensee Maria, facility staff, and Reporting Party (RP). Medical records and facility records were obtained and reviewed. The Department has determined the following as it relates to the above complaint allegation. Continued on LIC 9099 - C... Substantiated Continued from LIC 9099... LPA Valerio conducted interviews with the administrator and facility staff on 05/20/2021 and 06/26/2021. During the interviews, the Administrator Euforino and facility staff could not remember the exact dates of Resident 1 (R1) stay at Sunny Peace 1. Administrator Eurforino stated R1 was at the facility from 12/23/21 to 12/31/21. Facility medical records showed medications were given to R1 on dates 12/24/21 until the morning of 12/31/21. LPA Valerio reviewed the facility's Admission Agreement, section 9, discusses the Refund Policy. The refund policy states the following: A. The Agreement must indicate whether or not all, or any portion(s), of a payment will be refunded. There are no preadmission fees or deposits against damages being charged prior to the resident moving in or during the resident's stay. B. Refunds will be granted as follows: If the resident has to move for a higher level of care, a refund will be delivered within two weeks after all of the residents items have been removed. (See attached policies if the Department orders a relocation order or when the resident dies) C. If the resident leaves the facility temporarily, the holding rate for his/her room is $___ per day. The total monthly rate set forth in the admission agreement __ will _x_will not be prorated on a daily basis upon the resident's admission to, or permanent departure from, the facility during the month. H&S Code Section 1569.884 LPA Valerio reviewed American River Home Care medical records for R1, electronically signed on 01/02/2021. According to medical records, R1 was transferred to Kaiser South on 12/28/2021. According to RP, R1 was at the facility from 12/23/21 until 12/28/21. R1 did not return to the facility due to needing a higher level of care. The RP confirmed that they did not receive or complete discharge paperwork for R1. LPA Valerio attempted to review R1's inventory sheet to determine the length of time R1's belongings were in the facility. Administrators informed LPA Valerio an inventory sheet was not completed for R1. Continued on LIC 9099-C Page 3... Continued from Page 2 LIC 9099- C... The RP and Administrator of Sunny Peace 1 stated they communicated via phone regarding R1's hospital stay, admission agreement, and refund. LPA Valerio learned there were no documentation of alleged conversations. Based on LPA's interviews, medical record review, and facility record reviews, the preponderance of evidence standard has been met, 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 9099-D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was held with Licensee Maria Carrasco and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Aug 30, 2021 · control 27-AS-20210517115650

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Sep 30, 2021

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not follow their refund policy as stated in their admission agreement. Licensee did not issue a refund after R1 was transferred to the hospital and did not return to facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 30, 2021

Plan of correction: Licensee stated she will review the current admission agreement, update as needed, and ensure to adhere to agreed admission agreement with residents and responsible parties. Licensee will send amended admission agreement to LPA via e-mail by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a case management visit. LPA Valerio was met by staff and was screened for COVID-19 symptoms prior to being allowed entry. Facility Staff confirmed resident nor staff have experienced any signs or symptoms of COVID-19 in the last ten days. During a complaint investigation (21-AS-2021051715650), LPA Valerio attempted to retrieve an inventory sheet for Resident 1 (R1). Administrator informed LPA Valerio that an inventory sheet, a required document per Title 22 regulations, was not completed for the resident. During today's unannounced case management visit, LPA Valerio requested to see Admission Packets for current residents. LPA Valerio observed 5 out of 6 residents did not have an LIC 621 recorded in their file. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during this visit. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was held, and a copy of the report was left with Licensee Maria Carrasco .the state’s words, verbatim · CDSS document, Aug 30, 2021

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.153 · Plan of correction due date: Sep 13, 2021

569.153. A theft and loss program shall be implemented by the residential care facilities for the elderly...(d) A written resident personal property inventory is established upon admission... Inventories shall be written in ink, witnessed by the facility and the resident or resident's representative, and dated. This requirement was not met as evidenced by: Based on observations and interviews, Licensee stated the facility did not obtain an inventory sheet for R1 and currently does not have inventory sheets for 5 out 6 residents in care. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 30, 2021

Plan of correction: Licensee stated she will complete the LIC 621 for all residents and send a scanned copy to LPA Valerio by POC due date.