Padua Assisted Living 2

Allegation investigated: Resident was hit by staff member Staff member attempted to hit resident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Angelita Dayoan and explained the purpose of the visit. This investigation consisted of observation, interviews with staff, residents, and a local police officer, as well as review of facility records. LPA Moleski interviewed four staff members. Four of these (S1-S4) said they were not aware of any violence at the facility and did not have any concerns in this area. S1 denied hitting residents or attempting to do so. Three of five residents interviewed (R2-R4) were not aware of any violence at the facility and/or did not share concerns in this area. R1 said that S1 hit R2, and attempted to hit R1. R5 said that S1 has pushed R2. [continued on 9099-C] Unsubstantiated LPA Moleski did not observe any unusual marks, such as bruising or lacerations, on R1 or R2. LPA Moleski interviewed a local police officer who responded to allegations of physical abuse at this facility on August 17, 2023. The officer said R1 was not aware of any allegations of abuse at the time of the police visit, and R2 did not have any marks visible. The officer did not believe the allegations were substantiated based on the information obtained by police. The department has determined the following as it relates to the allegations that a resident was hit by a staff member and a staff member attempted to hit a resident: Based on interviews with staff members, residents and with a local police officer, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Dayoan.the state’s words, verbatim · CDSS document, Sep 6, 2023 · control 27-AS-20230817171937

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with Angelita Dayoan and explained the purpose of the visit. LPA Moleski observed a large, purple bruise on a resident's (R1) cheek and around the eye. LPA Moleski interviewed two staff members (S1-S2), who said the resident fell on Monday, August 28, 2023. S1 said R1's family members were notified of the fall. S1 said R1's medications were recently changed, and she has been dizzy as a result. S1 said R1 was not taken to a hospital afterward. S1 was present during the fall, according to S1. LPA Moleski interviewed R1 and asked what happened to her face. R1 said she didn't know. LPA Moleski reviewed a handwritten narrative written by S1. The narrative described R1 bumping her forehead. According to the narrative, R1's family and Dayoan were notified. LPA Moleski did not receive this handwritten narrative or any other incident report within seven days. This facility is being cited per 22 CCR Section 87211(a)(1)(D). A civil penalty is being assessed due to repeat violations. An exit interview was held with Dayoan. Appeal rights and a copy of this report were left with Dayoan.the state’s words, verbatim · CDSS document, Sep 6, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 13, 2023

Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." This requirement was not met as evicenced by: Based on observation and interviews, a resident suffered injuries after a fall on Monday, August 28, 2023, and an incident report was not sent to licensing within seven days, as required, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Sep 6, 2023

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

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with administrator Angelita Dayoan and explained the purpose of the visit. During the course of a prior complaint investigation, LPA Moleski learned of a fire that occurred in the backyard of the facility which left burnt fencing. LPA Moleski previously observed the burnt fencing and took photographs. LPA Moleski spoke with a resident (R1) who said he had accidentally lit the fire while smoking in the backyard. LPA Moleski interviewed two staff members (S1-S2). S2 said she was present when the fire was lit and put water on it. S1 was not working on the day of the fire. No incident report was received regarding this fire. This facility is being cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Dayoan. Appeal rights and a copy of this report were left with Dayoan.the state’s words, verbatim · CDSS document, Aug 17, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 24, 2023

"(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." This requirement was not met as evidenced by: Based on interviews with R1, S2, and based on observation of burnt fencing in the facility's backyard and review of licensing records, the licensee did not submit an incident report for this fire, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Aug 17, 2023

Plan of correction: The licensee previously conducted a staff training on incident reporting and sent a copy to LPA Moleski. This POC will be cleared.

Allegation investigated: Staff are not properly supervising residents in care resulting in residents wandering from the facility

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with administrator Angelita Dayoan and explained the purpose of the visit. This investigation consisted of interviews with Dayoan, staff members (S1-S3), residents (R1-R4), R1’s sibling, R1’s independent living specialist, and R1’s Alta California Regional Center (ACRC) service coordinator, review of resident records, and review of facility records. In interviews, Dayoan, S1, and S3 described an incident in which R2 left the facility unaccompanied. Dayoan said R1 turned off the alarm on a door leading outside from R1’s bedroom, which allowed R2 to leave without being noticed. Dayoan said this incident occurred on July 10, 2023. Dayoan said R2 was gone for five or 10 minutes before staff noticed R2 was gone. S1 said R2 walked about a block and was gone for about 30 minutes before staff noticed. S3 said the alarm on R1’s exterior door sometimes does not work, and that R2 left through this door without staff noticing. [continued on 9099-C] Substantiated R1 said R1 has turned off the alarm on this door. Dayoan, S1, S2, and S3 said R2 sometimes tries to leave the facility to go to church. R2 said R2 goes to church alone. R2’s LIC 602 indicates that R2 cannot leave the facility unassisted. In interviews, Dayoan said she did not know where R1 was discharged after being hospitalized. Dayoan said R1 was discharged on July 2, 2023. Dayoan could not provide any discharge paperwork from this hospital visit. Dayoan said R1 was hospitalized after leaving the facility without authorization and asking a neighbor to call emergency services. R1’s sibling said they unintentionally ran into R1 on the street around this time. R1 corroborated the sibling’s account of their run-in on the street. R1’s sibling said R1 was not accompanied by staff at the time. R1 said that after being discharged from the hospital, R1 was given a bus pass. R1 said R1 stayed at a friend’s house for one night, and spent multiple other days living on the street. R1’s ACRC service coordinator said ACRC was notified of R1’s general whereabouts by R1’s sibling after their contact with R1. Dayoan said R1 returned to the facility after being discharged a second time from a different hospital. LPA Moleski reviewed discharge paperwork from this hospital dated July 5, 2023 which show R1 was returned to Dayoan’s facility. R1’s LIC 602 indicates that R1 cannot leave the facility unassisted. R1’s ACRC service coordinator said ACRC has received calls from other community members notifying ACRC that R1 was out in the community. LPA Moleski reviewed a handwritten statement written by S2. In this statement, S2 described an incident that occurred on July 11, 2023, around 5 p.m. S2 wrote that S2 was out walking with R1 when R1 got onto a bus. S2 wrote that S2 did not have bus fare. R1 left on the bus unaccompanied, according to S2’s statement. R1 corroborated the events described in S2’s statement. Dayoan said she filed a missing person report with the local police department after this incident. LPA Moleski reviewed a missing person report regarding R1 dated July 11, 2023. Dayoan said R1 was returned to the facility that same day, around 10 p.m. R1 said R1 called Dayoan and was picked up that same day, around 10 p.m. The department has determined the following as it relates to the allegation that staff are not properly supervising residents in care resulting in residents wandering from the facility: [continued on 9099-C] Based on interviews with Dayoan, S1, S3, R1, R2, R1’s sibling, and R1’s ACRC service coordinator, and based on review of resident records and facility records, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87411(a). An exit interview was held with Dayoan. Appeal rights and a copy of this report were left with Dayoan.the state’s words, verbatim · CDSS document, Aug 10, 2023 · control 27-AS-20230710160617

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 11, 2023

Personnel Requirements - 22 CCR Section 87411(a): "Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services." This requirement was not met as evidenced by: Based on interviews and document review, R1 and R2 were permitted to leave the facility without assistance, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Aug 10, 2023

Plan of correction: Licensee agrees to send a written plan stating how staff will maintain supervision over residents as required to LPA Moleski by the POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit to follow up on incidents which were discovered during the course of a complaint investigation. LPA Moleski met with administrator Angelita Dayoan and explained the purpose of the visit. LPA Moleski did not receive incident reports for any of the resident absences involving R1 and R2 which were discovered during that complaint investigation. This facility is being cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Dayoan. Appeal rights and a copy of this report were left with Dayoan.the state’s words, verbatim · CDSS document, Aug 10, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 24, 2023

Reporting Requirements 22 CCR Section 87211(a)(1)(D): "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." This requirement was not met as evidenced by: Based on interviews and record review conducted during a complaint investigation, no incident reports were sent for R1 and R2's unauthorized absences, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Aug 10, 2023

Plan of correction: Licensee agrees to review reporting requirements and send LPA Moleski a statement asserting so. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Angelita Dayoan and explained the purpose of the visit. LPA Moleski reviewed three resident files (R1-R3) and three staff files (S1-S3). S2's health screening report did not indicate that a chest x-ray or tuberculosis skin test were performed. LPA Moleski reviewed medication storage and medication administration records (MARs) for R4. LPA Moleski counted 18 signed administrations of a medication which had been filled in a 14-count bottle. Dayoan said a staff member signed the MAR when doses were not, in actuality, given. LPA Moleski toured the facility with Dayoan and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. While inspecting a resident bedroom, LPA Moleski observed a bed bug shell present on a resident's bed. On another bed in the same room, LPA Moleski observed spotting on a pillowcase. LPA Moleski photographed the shell and the spotting. The facility temperature was 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 109 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. [continued on 809-C] LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed two staff members (S1-S2) and two residents (R3-R4). This facility is being cited per 22 CCR Sections 87411(f), 87465(a)(4) and 87303(a). An exit interview was held with Dayoan. Appeal rights and a copy of this report were left with Dayoan.the state’s words, verbatim · CDSS document, Jul 24, 2023

Allegation investigated: Staff did not meet resident's needs Staff did not safeguard resident's personal belongings Staff denied to provide resident's authorized representative with a refund

Licensing Program Analyst (LPA)s Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by . The investigation was conducted by the Department. The investigation consisted of interviews with staff, interviews with witnesses, review of resident medical reports, facility chart notes and facility resident files. The Department has determined the following as it relates to the allegations: Staff did not meet resident's needs, Staff did not safeguard resident's personal belongings, and Staff denied to provide resident's authorized representative with a refund Continued on LIC 9099 - C... Page 1 of 2 Substantiated On 2/7/2023 LPA Ivey Canady interviewed S1 regarding the care services provided by the facility to R1. S1 stated the primary caregiver for R1 was S2. On 2/7/2023 LPA Ivey Canady interviewed S2 regarding the care provided by the facility and S2 purported not to be in the facility during the 3-4 days that R1 was at the facility, and purported not to be active in R1's care. According to the interview with S2, S2 was also away at a doctor's appointment when emergency personnel were called to the facility regarding R1. On 2/7/2023 S1 gave testimony that most of the calls received from R1's family regarding the status of R1, had to be rerouted back to the facility because S1 was not present at the facility. According to witness statements, S3 told R1's family that R1 had been fed a spaghetti dinner. However, based on interviews from S1, R1 had begun to decline and remained unconscious from the beginning of R1's arrival to the facility. Furthermore, S1 stated S2 had given R1 the spaghetti dinner, however testimony from S2 is that S2 was never in the presence of R1. Therefore, the allegations Staff did not meet residents’ needs is Substantiated. Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. On 8/12/2022 LPA Ivey Canady interviewed S1 regarding the status of R1's personal belongings. According to the interview with S1, the caregivers at the facility take out all belongings and annotate belongings on official LIC form. LPA requested copy of form. LPA did not receive a copy of the form. Based on interview with S1, the beginning of the interview with S1, there is a 2 day wait to put away belongings. Further along in the same interview, S1 made a correction and said belongings are put away immediately. On 2/7/2023, LPA requested the status of R1's left over personal belongings. S1 stated those particular belongings were never at the facility. However, according to interviews with witnesses, the belongings in question were left at the facility when R1 was taken by ambulance to the hospital. Based on interviews with S1, R1 had been fed particular meals. However, R1 would have not been able to be fed those particular meals without belongings that S1 stated was never at the facility. Therefore the allegation Staff did not safeguard resident's personal belongings is Substantiated. Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Cont on 9099-C Page 2 of 3 Exit interview held, report given to Administrator On 2/7/2023 LPA Jamie Ivey Canady interviewed Staff 1 (S1) regarding current allegations. According to interview with S1, refund to R1's family was submitted and processed on 9/30/2022. According to interview with witness several attempts were made to secure a refund from the facility after the death of R1. Based on record review, refund was not made within 5 business days of R1 death as in accordance with facility admission agreement signed on 7/9/2022. Therefore, the allegation Staff denied to provide resident's authorized representative with a refund is Substantiated Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview with Administrator. Appeal rights and report given. On 1/20/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady interviewed R1 family witness regarding current allegations. On 2/7/2023 LPA Ivey Canady interviewed S1 regarding current allegations. According to interviews, there were many calls regarding the welfare of R1. During the calls the status of R1 was consistently asked. Based on interviews, many calls were placed to facility licensee cell number. According to interviews, there were times the phone calls to the cell phone were routed to the facility land line to get a real time status of the condition of R1. According to interviews with witness and S1, the question to speak directly to R1 was not asked. Therefore, the allegation Staff denied resident phone calls is Unsubstantiated. An unsubstantiated finding means 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.the state’s words, verbatim · CDSS document, Feb 22, 2023 · control 27-AS-20220802140801

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 22, 2023

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided...This was not met as evidenced by: According to interviews with staff, the Licensee did not ensure R1 was appropriately monitored during the stay at the facility. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: Licensee stated there will be staff training regarding resident observation and will submit training sign in sheet to LPA no later thatn 5pm 2/23/2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b · Plan of correction due date: Feb 22, 2023

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted...This was not met as evidenced by: Based on interviews with Staff and Witness, the Licensee did not ensure R1 belongings were secured as directed by Title 22 Regulations. This poses a potential health and safety risk for persons in carethe state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: Licensee stated there will be a receipt system created whereas resident's families will sign acknowledging that belongings are received. Licensee will send a copy of the receipt system no later than 3/22/2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(5)(A) · Plan of correction due date: Feb 22, 2023

87507(5)(A)Admission Agreements (5) Refund conditions.(A)Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death...This was not met as evidenced by: According to interviews, Licensee did not ensure R1 family received refund as described in facility Admission Agreement. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: Licensee stated there will be staff training regarding providing refunds. Licensee will send a copy of staff sign in sheet vi.a email to LPA no later than 3/22/2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a health and safety check on the residents residing in the facility on 2/8/23 at 2:35p. LPA met with Susana Ancheta, Caregiver and stated the purpose of the visit. Community Care Licensing held an Office meeting on 12/20/22 as a result of an Audit investigation. This Case Management visit is to ensure the health and safety of the residents. During the visit, LPA observed required furniture, and lighting throughout the facility. The temperature inside the facility measured at 73*F which is within the required range of 68-85*F. The hot water temperature was measured 110.6*F which is within the required range of 105-120*F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the home. The facility has central heating and air. The facility is approved for a hospice waiver for 4 of which there no residents receiving hospice care services at this time. LPA observed required postings during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, Feb 8, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson arrived at the facility unannounced to open a ten day complaint yesterday. In addition to opening the ten day complaint, LPA conducted a case management inspection to check on the health, safety, and welfare of the clients in care. LPA met with Staff and explained the reason for the inspection. LPA inspected the physical plant, inside and out. Fire extinguishers are in compliance. The hot water temperature is at 107 degrees F, which is within the required range. Facility is maintained at a comfortable temperature. Residents in care appeared to be safe and have no imminent health/safety concerns observed. LPA inspected facility food supplies, which appeared to be adequate. As a result of this inspection, No deficiencies were cited. Exit interview conductedthe state’s words, verbatim · CDSS document, Aug 10, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Annual Inspection visit. LPA was allowed entry into the home and is licensed for a capacity of 6 non-ambulatory. LPA met with Administrator and explained purpose of visit. LPA and Administrator toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the residents and staff social distancing with masks during this visit. LPA observed the kitchen area, dining area, bedrooms, bathrooms, storage areas, and laundry room. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature was measured using the facilities thermometer to be 110.5*F which is within the required range of 105-120*F. The temperature inside the facility measured on the facilities thermostat to be 75*F which is within the required range of 68-85*F. The facility has alarms on each exit. LPA observed there were food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. The first aid kit was complete. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the home. Facility also has central heating and air. LPA observed the area where the staff and resident files are locked and readily available for review. A review of (3) facility resident records was conducted and have all required documents for Community Care Licensing (CCL). A review of (2) facility personnel records was conducted. All staff is fingerprint cleared and associated to the facility. All staff have current First Aid/CPR certifications on file. Facility is conducting initial and continuing training as required. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 6, there were no deficiencies cited during this visit. Exit interview was conducted with Administrator and a copy of this report was provided at facilitythe state’s words, verbatim · CDSS document, Jul 27, 2022

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 4/12/2022 at 4:15pm to conduct a health and safety check on residents receiving care and supervision. LPA was met by Angelita Dayoan and stated the purpose of the visit. LPA toured the facility to ensure there no areas that would pose a health, safety or personal rights risk to residents in care. Currently, there are 5 residents receiving care and supervision. The fire extinguishers, carbon and smoke detectors were present. LPA observed residents eating and participating in individual activities and visitors present.. LPA observed 2-day perishables and 7-day non-perishables. The hot water measured at 120*F which is within the required range of 105-120*F. The temperature inside the facility measured at 73*F which is within the required range of 68-85*F. 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 did not observe any health and safety concerns during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Apr 12, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA's temperature was taken prior to being allowed entry into the facility. LPA confirmed with staff that zero residents or staff have displayed signs or symptoms of COVID-19 in the last 10 days. LPA explained the purpose of the visit and met with staff on shift. LPA Valerio interview 1 staff. Staff stated the licensee is Angelita Dayoan and the Administrator is Karl Padua. No notices of change of ownership has been given to staff or residents. Administrator Certificate #6057871740 Expiration Date: 11/16/2022. According to facility records, Karl was designated as the acting administrator on 08/20/2021. LPA interacted with Resident 1 (R1) during today's visit. R1 stated R1 has lived at the facility for one year and enjoys living here. R1 was observed watching television, eating R1's favorite crackers, and interacting with the staff. Residents 2 - 5 were in their room taking a nap. LPA observed the following documents posted in the common area for public review: LIC 500 Personnel Roster, LIC 309 Administrative Organization, COVID -19 Informational, LIC 308 Designated Responsibility of Facility, most recent licensing report, personal rights, most recent PIN from CCLD, and Emergency Plan Based on observations and interviews, no deficiencies were observed. Exit interview held with facility staff and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Feb 25, 2022

Type of visit: Required - 1 Year

On 8-18-21 at 3:00pm Licensing Program Analyst (LPA) Tirzah Hubbard arrived unannounced to conduct a Required – 1 Year inspection. LPA met with Admisitrator Karl Padua, and stated the purpose of today’s visit. LPA were allowed entry into the facility that is licensed to serve a total capacity of 6 clients. LPA interacted with a random number of residents during this visit. The physical plant was tour inside and outside to ensure the safety of the residents. All required furniture were observed. LPA observed residents engaging in activity, wearing a mask and practicing social distancing. LPA observed the facility conducts fire drills monthly. Census: 4 Staff: 2 All required COVID measures were observed. All bedrooms contained a dresser, bed, and night stand.The flooring of the facility has been replaced. LPA observed the thermostat 74*F temperature inside the facility hallway was measured at 71 *F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 113 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed 3 of 3 medications counted properly labeled and stored, matching medication administration records (MAR).The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed there were food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. Mitigation Plan was submitted and approved. Upon a file review the following items were discussed to be submitted with any changes annually: Criminal Record Clearances LIC536 Administrative Organization LIC309 Designation of Administrative Responsibility LIC308 Personnel Report LIC500 Qualifications of Administrator/Facility Manager- Administrator certificate Emergency Disaster Plan LIC610D LPA discussed the procedures of the quarantine and isolation and the importance of following Covid-19 procedures. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, there were no deficiencies cited during this visit. Exit interview held and a copy of report was given.the state’s words, verbatim · CDSS document, Aug 18, 2021