Comfort Living Elder Care 3

Allegation investigated: Staff do not keep the facility free from pests Staff are not providing adequate care and supervision to the residents

On 10/06/2023 at 8:00 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care staff, Abietuwaja Edokpolo and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5. A brief interview was conducted with care staff. LPA Lee also read the report findings to administrator, Mariam Soumahora, via telephone because administrator was not present during today’s visit. At 8:30 AM, LPA Lee toured the facility with care staff. LPA Lee also reviewed staff criminal record clearances and 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. Allegation: Staff do not keep the facility free from pests. It was alleged that the staff did not keep the facility free from pests. This investigation consisted of records reviewed, interviews with staff and residents. It was learned that 4 out of 5 residents had not witnessed any pest in the facility and has no concerns. Continued LIC 9099-C Unsubstantiated The investigation also revealed that 3 out of 3 facility staff denies seeing any pest in the facility. It was learned that the facility is receiving pest control services from “California Pest Control.” The facility received services on 08/14/2023 from 4:55 to 5:45 PM, 08/29/2023 from 4:48-5:38 PM and 09/19/2023 from 3:21-3:34 PM. Per LPA Lee visit and tour of the facility on 09/26/2023 and today’s visit, LPA Lee did not observe any pest in the facility. Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff do not keep the facility free from pests. Allegation: Staff are not providing adequate care and supervision to the residents. It was alleged that the staff are not providing adequate care and supervision for the residents. This investigation consisted of records reviewed, interviews with staff and residents. It was learned that 4 out of 5 residents has not witnessed any facility staff not providing adequate care and supervision to the resident. It was also learned that 4 out of 5 residents have no concerns regarding care and supervision. The investigation also revealed that 3 out of 3 facility staff denies not providing adequate care and supervision to the residents. Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff are not providing adequate care and supervision to the residents.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 27-AS-20230919110101

Type of visit: Post Licensing

On 03/30/2023 at 8:25 AM, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to conduct a post-licensing inspection. LPA Lee arrived and was greeted by Caregiver, Teresita Agamanos. LPA Lee asked Caregiver, Teresita to contact the Facility Designated Administrator (FDA) to let them know that Community Care Licensing (CCL) was present at this time. Licensee/FDA Mariam Soumahoro stated that she is in San Francisco and will come to the facility, but if she gets stuck in traffic, then caregiver Teresita Agamanos can assist with the post-licensing visit. LPA met with caregiver Teresita Agamanos and explained the purpose of the visit. Administrator Certificate # 6049437740 and will expires on 08/22/2024. There are currently four (4) residents currently living at the facility. LPA toured and inspected the physical plant inside and outside with caregiver to ensure there were no health and safety concerns. LPA observed the kitchen, bedrooms, bathrooms, and common areas. LPA observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed the rooms to be clean and organized with comfortable furnishings. The hot water temperature was measured at 112.8 degrees Fahrenheit. The temperature inside the facility measured at 69 degrees Fahrenheit which was within the required range of 68-85 degrees Fahrenheit. 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. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher and first aid kits were up to date. Fire extinguisher was last service on 11/07/2022. LPA observed smoke and carbon monoxide detector in the facility were in good repair. LPA observed the following posted in the entrance of the facility. See Something Say Something poster, Ombudsman poster, Reporting Requirements, Resident Personal Rights, Evacuation Routes and facility license was all posted as required. Report continued on 809-C LPA reviewed (2) resident files and (3) staff files, including criminal record clearances. LPA confirmed all residents’ files have required records. 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. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held with caregiver and a copy of report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 30, 2023

Allegation investigated: Resident developed pressure injuries due to staff not turning resident as needed.

LPA Lewis made an Unannounced visit to the facility to deliver findings on the allegations listed above. LPA was met by staff and explained the purpose of the visit. Based on Hospice notes dated in January 2023 and staff interviews allegation is Substantiated. The Department has investigated the compliant and determined the allegation is Substantiated. 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 were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. A civil penalty in the amount of $500 is being issued on today's visit due to the violation resulting in an unstageable wound. Failure to correct the deficiency may result in additional civil penalties. At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 15610.67 Appeal rights were provided. Exit interview was conducted and a copy of this report was given. Substantiatedthe state’s words, verbatim · CDSS document, Mar 27, 2023 · control 27-AS-20230203170904

Allegation investigated: Resident developed pressure injuries due to staff not turning resident as needed.

Based on a review of the hospice notes dated in January of 2023 , and interviews wiht the staff. The allegation is substantiated. 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 were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. A civil penalty in the amount of $500 is being issued on today's visit due to the violation resulting in an unstageable wound. Failure to correct the deficiency may result in additional civil penalties. At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 15610.67 Appeal rights were provided. Exit interview conducted and a copy of the report and appeal rights were given. Substantiatedthe state’s words, verbatim · CDSS document, Mar 24, 2023 · control 27-AS-20230203170904

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 4, 2023

87464 (f)(1)Basic services care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met based on The department's findings. The facility failed to prevent resident from developing pressure injuries due to staff not turning resident as needed. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Licensee shall review the regulation to ensure residents recieve Basic services care and supervision as defined in Section 87101(c), and submit a letter to the LPA stating they understand the regulation.

Type of visit: Case Management - Incident

LPA Lewis made an Unannounced visit to the facility to conduct a case management visit from a complaint that was filed. LPA was met by staff and explained the purpose of the visit. Administrator joined 20 minutes later. Based on the review of resident files during the complaint investigation the facility does not have a bedridden clearance but had two (2) bedridden residents. It was learned that R1 required assistance with transferring in/out of bed and to/from R1's wheelchair, toilet, It was learned that R1 was deemed to be bedridden and required assistance with transferring, toileting, and required to be turned/pivoted on set intervals throughout the day and night. Administrator claims Resident 2 is not bedridden. Will check with hospice and their Physician. LPA and Administrator checked residents file and their 602 (Physicians report) and it does not say the resident is bedridden. The 602 was completed inn August of 2022. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights and a copy of the report was given.the state’s words, verbatim · CDSS document, Mar 20, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202 · Plan of correction due date: Mar 21, 2023

87202(a) Fire Clearance. All facilities shall maintain a fire clearance. Prior to accepting persons over 65 years of age and/or non ambulatory persons the licensee shall notify the licensing agency and obtain an appropriate fire clearance. LPA observed that R1 is bedridden. This is evidenced by observation. LPA observed that R1 is bedridden. This poses an immediate risk to resident in care.the state’s words, verbatim · CDSS document, Mar 20, 2023

Plan of correction: The Licensee agrees to update plan of op and emergency plan as stated in TA.

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee arrived unannounced to conducted a Pre-Licensing CHOW Inspection of the facility to ensure compliance with Title 22 regulations. LPA Avelina Martinez and LPA Pang Lee met with Susan Nagtalon, and explained the purpose of today's visit. Facility has a fire clearance for 6 non-ambulatory residents. Administrator,Mariam G. Soumahoro will be the Administrator of this facility. LPAs inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. The facility has the required postings, and has Covid-19 postings throughout the facility. The facility has one main Covid-19 screening entry, and log in sheet. The facility has established resident and staff files. In addition, the facility has a first aid it. The facility smoke detectors, carbon detectors, and fire extinguishers are in good repair. The facility has an adequate food supply, and has kitchen utensils. Also the water temperature measured at 120 degrees, and the facility temperature was 75 degrees. The facility has a public telephone, and has an area for activities. Resident bedrooms were furnished, and resident bathrooms were in good repair. Mariam has other licensed facilities, and has completed component 3 prior to this pre-licensing. Component 3 has been waived for this pre-licensing. The applicant has passed the pre-licensing component of the application process. LPA Martinez will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. An exit interview was conducted, and a copy of this report has been provided to the facility.the state’s words, verbatim · CDSS document, Dec 13, 2022

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): YES (4) Method: Telephone call with CAB COMP II Participants: Muamoudou Soumahoro & Mariam SoumahoroApplicant/administrator Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1.Facility operation: License type, client/resident populations, and program 2.Staff qualifications and responsibilities 3.Applicant and Administrator qualifications 4.Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5.Grievances, Complaints, Community resources 6.Physical plant, food service 7.Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property 8. Discussed the COVID-19 Mitigation Plan & PIN emailedthe state’s words, verbatim · CDSS document, Nov 21, 2022