Aegis Assisted Living of Carmichael

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

Licensing Program Analysts (LPAs) Angela Hood and Jaynae Boyles arrived at the facility unannounced on 8/23/2023 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 3/28/2023-3/28/2025. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPAs met with the Executive Director, Tracy Lehner. During today's visit, LPAs reviewed the following stipulations of the order: 1. Staff shall have criminal record clearance -LPAs checked criminal record clearance for all staff 2. Staff have current CPR training certification -LPAs observed current CPR certifications for staff 3. All medications and toxins shall be locked away and inaccessible to residents -LPAs observed all medications and toxins to be locked away 4. Facility shall be clean, safe, and sanitary -LPAs toured facility which was clean, safe, and sanitary 5. Facility shall conduct monthly quality assurance audits for 1 year -LPAs observed monthly quality assurance audit reports LPAs observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Aug 23, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Hood arrived at the care home unannounced to conduct a case management inspection related to an incident report received by the Department. On 8/5/23, an incident report was received regarding a memory care resident (R1). On 8/1/23, R1 was observed to have a cough, chills, and 103.1 degree F fever. R1 was tested for COVID-19 and the results came back negative. R1 was transported to the hospital and was discharged with a diagnosis of severe sepsis with acute organ failure and UTI. R1 returned to the facility with a new medication order of antibiotics. During today's visit, LPA toured the memory care units and observed R1 in the activity room. LPA was informed that R1 does not have frequent UTIs. R1 has a Dementia diagnosis and experiences confusion. R1's fever was an indicator to the facility staff to have R1 sent to the hospital. Upon return from the hospital, R1 is back at baseline. R1 has a follow-up appointment scheduled with their primary care physician on 8/15/23. Facility staff provide R1 assistance with toileting needs and keep track of set times for assistance electronically. LPA obtained a copy of R1's service plan and electronic tracking of R1's toileting needs for the week of 8/1/23-8/9/23. There are no deficiencies noted during today's inspection. Exit interview was conducted. Copy of report provided to Executive Director.the state’s words, verbatim · CDSS document, Aug 9, 2023

Type of visit: Case Management - Other

On 8/1/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with the Administrator. On 7/19/23, the department issued a citation for this facility. Today's visit is to modify the citation issued on that date. No new incident related to the 7/19/23 citation have occurred. The licensee has completed the plan of correction. As a result of today’s inspection, no new deficiencies were noted. Report reviewed. Copy of report and providedthe state’s words, verbatim · CDSS document, Aug 1, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jul 26, 2023

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, … residents in privately operated residential care facilities … following personal rights: (8) To be free from …financial exploitation, .... This requirement was not met based on records and statements that S1 financially exploit three residents. This posed a potential risk to resident’s.the state’s words, verbatim · CDSS document, Aug 1, 2023

Plan of correction: Licensee has submit proof of inservice regarding employees communicating issues or concerns regarding co-worker actions or inactions to management to address the concerned.

Type of visit: Case Management - Other

On 7/19/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit findings and met with Executive Director (ED), Tracy Lehner . The department has received theft/ loss reports regarding two (2) residents R1 and R2. In April 2023 and again in July 2023, R1 reported losses of $200 in April and July 2023 incidents. Also in July 2023, it was reported that R2 had $700 missing. All incidents of theft/ loss noted in this report were reported as required. Local law enforcement have been notified and their findings are not available at this time. The department collected records and conducted interviews of the three incidents. Visits to the facility to investigate the incidents occurred on 4/27/23, 7/6/23 and 7/11/23. It was found that R1 and R2 had their money in their rooms. Both R1 and R2 had lock boxes available to them and in two of the three incidents, money was taken from the lockboxes. Neither R1 nor R2 identified suspects for stealing their money. On 7/11/23, LPA Mknelly conducted a facility visit and discussed the licensee’s internal investigation results. Interview statements and a video provided to the Director found circumstantial evidence of suspicious behavior of S1 over the previous months. Staff reported S1 to be in areas of the community to which she was not assigned. S1 was alleged to be in the vicinity of the facility when food or supplies were found missing in the facility. S1 had been observed to be in a resident room when that resident was away at the hospital. In these previous observations, S1 was not caught with stolen items. A video, provided to the Director, by a person who knew S1, of the inside of S1’s home showed what appeared to be trash bags from the same supplier as the facility’s and what appeared to be a vacuum clearer missing from the facility. Based on the evidence to date, S1’s employment was terminated. On 7/18/23, the ED contacted LPA Mknelly by phone to notify LPA that a third resident, R3, reported suspicious activity on their debit card. R3’s family reported that R3’s card had had the account’s email address and password changed. The ED recognized the information as being related to people known to S1. As a result of this investigation, LPA finds allegation to be (S) 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 cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care or personal rights. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Jul 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jul 26, 2023

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, … residents in privately operated residential care facilities … following personal rights: (8) To be free from …financial exploitation, .... This requirement was not met based on records and statements that S1 financially exploit three residents. This posed an immediate risk to resident’s personal rights.the state’s words, verbatim · CDSS document, Jul 19, 2023

Plan of correction: Licensee submit proof of inservice regarding employees communicating issues or concerns regarding co-worker actions or inactions to management to address the concernd. POC date is 7/26/23,

Type of visit: Case Management - Other

On 7/11/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Executive Director (ED). On 7/10/23, the department received an incident report of resident theft or loss. LPA was informed by ED that an internal investigation has been conducted and a caregiver suspected has been suspended. The report was given to local police as well. LPA interviewed R1. LPA also received records regarding S1. Further investigation is needed. As a result of today’s inspection, no deficiencies were noted at this time. Report reviewed. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 11, 2023

Type of visit: Case Management - Other

On 7/6/23, Licensing Program Analyst (LPA) Kevin Mknelly, met with the Director to follow-up on a recent incident and report regarding R1 and a death report for R2. R2 had an unexpected death. Interviews with director, RN and med tech found no lack of care or supevision at this time. Director will forward the death certificate when received. R1 had a theft/loss report in June. R1 was off site and unavailable for interview. LPA will contact R1 for interview. As a result of today’s inspection, no deficiencies were found at this time. Report was reviewed with the Director and copy provided.the state’s words, verbatim · CDSS document, Jul 6, 2023

Type of visit: Case Management - Other

On 6/16/23, Licensing Program Analyst (LPA) Kevin Mknelly, met with the Director to follow-up on a recent incident and report regarding R1. R1 is a resident in memory care that continues to, at times, have aggressive intentions. LPA and the Director discussed current and ongoing strategies and interventions which may be most effective for caregivers working with R1. The licensee is also exploring options, with R1's responsible parties, for other communities which may meet R1's needs. LPA and the Director observed and met with R1 in his community. R1 was engaging and not demonstrating overt behaviors during the time of the visit. As a result of today’s inspection, no deficiencies were found at this time. Report was reviewed with the Director and copy provided.the state’s words, verbatim · CDSS document, Jun 16, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 6/13/23 to conduct a Required-1 Year Inspection utilizing CARE inspection tool. LPA met with the Executive Director and explained the purpose of the visit. LPA toured the interior of the facility together with Executive Director and maintenance director to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, (8) resident bedrooms as well as the rest of the physical plant. In the areas toured no immediate health, safety, or personal rights violations were observed. The residence was found to be clean, safe, sanitary and in good condition. Water temperature logs were checked and water maintained in required range. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. LPA reviewed 8 resident files and 7 staff files. Resident files reviewed are complete and current. Staff files reviewed were complete- training is ongoing. LPA advised that resident physician reports be reviewed when received and discrepancies between observation and physician's report be resolved. LPA requested licensee submit a copy of liability insurance, resident roster and staff roster. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jun 13, 2023

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

On 6/13/22, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit as well as an annual inspection (reported separately) and met with the Administrator . The purpose of the visit was to review compliance with conditions of the Stipulation. All conditions are met. The residence is clean, safe and sanitary. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report providedthe state’s words, verbatim · CDSS document, Jun 13, 2023

Type of visit: Case Management - Other

On 5/10/23, Licensing Program Analyst (LPA) Kevin Mknelly, met with Kelly Smitley to follow-up on an earlier case management visit on 4/27/23. Upon entering the facility, analyst completed electronic screening and sign in. Analyst followed facility's policy and wore a surgical mask. The incident reports discussed were submitted to the regional office on 4/14/23, 4/22/23 and 4/25/23. The report submitted on 4/14/23 was for a resident to resident incident of aggression of R1 toward R2. The report stated that on 4/13/23, (R1) “suddenly approached (R2) and slapped her on the face, grabbed her right shoulder and dragged her on her side.” Records and statement found R1 to have dementia and to be a resident in the memory care section of the facility with R2. There was no prior history reported to LPA of aggressive behavior by R1 toward other residents. The report submitted on 4/14/23 by Aegis LVN, S1, stated that “suggested 1:1 caregiver for (R1) and DPOA agreed.” On 4/27/23, Administrator stated to LPA that 1:1 caregiver resources were being sought through an agency and that the 1:1 services began for R1 on 4/26/23. The report submitted on 4/22/23, by S1, was for a resident to resident incident of aggression of R1 toward R3 occurred on 4/21/23. The report submitted by S1 for the 4/21/23 incident stated (R1) “ came to (R3) at her table and suddenly slapped and punched her on the left side of her face.” Facility evaluation of residents involved found no injuries to residents. As the identified 1:1 caregiver identified as needed for R1 was not established between 4/13/23- 4/26/23 for their aggressive “sundowning” behaviors, and a second aggressive incident occurred during that time, the licensee failed to insure there is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified as defined in CCR 87705(c )(4). Furthermore, LPA conducted additional reviews to staff working during the reported loss of money belonging to R4, sometime between the period of 4/20/23 for an upcoming outing. On 4/22/23 the money belonging to R4 was found to be missing. To date, the money has not been recovered and no witness to a theft have been found. However, on 4/21/23 and 4/22/23, staffing agency contracted staff, S2, was present and assigned to assist R4 and other residents. A criminal records clearance review of staff present at the facility found S2 to not have a criminal background clearance on file with the Department of Social Service. The agency that employed S2 and who contracted with the licensee is a staffing agency and not a home care organization. Nor were records found that S2 is a registered home care aid. Residency agreements state- person who provides client assistance in dressing, grooming, bathing, or personal hygiene. care, toileting, transferring and similar care must be provided by our staff. The licensee failed to ensure that any person who provides client assistance in dressing, grooming, bathing, or personal hygiene had undergone criminal record clearance as identified in Health and Safety Code 1569.17(b)(1)(C). S2 had worked at this facility greater that 5 days. Lastly, documents presented to LPA by the Administrator on 4/27/23 as well as a phone conversation with a representative of the staffing agency for whom S2 was employed found that only verification of mandated reporter training was on file for S2. The representative from the staffing agency confirmed that they are not aware of RCFE staff training Citations and civil penalties are therefore issued. Report was reviewed with the Director and copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, May 10, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: May 15, 2023

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: 4) There is an adequate number of direct care staff to support each resident’s … safety and health care needs as identified in his/her current appraisal. This requirement was not met based on statements and interviews regarding R1, 4/13/23 to 4/26/23. This posed an immediate risk to other residents.the state’s words, verbatim · CDSS document, May 10, 2023

Plan of correction: The licensee has addressed the immediate risk at this time. Licensee will will submit written procedures to be followed when a resident is identified as a risk to self or others that respod to that identified care need in a timely manner, by the POC date of 5/15/23.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.17(b)(1)(C) · Plan of correction due date: May 15, 2023

Fingerprints and criminal records of individuals in contact with clients (b) In addition to the applicant... apply to ... following persons: (1) (C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene… This requirement was not met based on records and statements that found S2 to have neither proof of certification nor criminal record clearance. This posed an immediate risk to residents in care. Civil penalties are issued.the state’s words, verbatim · CDSS document, May 10, 2023

Plan of correction: S2 was immediate removed from further presence at the facility and further contracts with the staffing agency was discontinued. Licensee will submit a policy for screening and onboarding of "agency"

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: May 24, 2023

Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living (ADL) shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met based on records review and interviews that found S2, as a staffing agency staff who provided ADL assistance to residents in care, did not have proof of required training either through the facility nor the staffing agency. This posed a potential risk to residents.the state’s words, verbatim · CDSS document, May 10, 2023

Plan of correction: Licensee will submit a policy for screening and onboarding of "agency" staff to insure required training is completed current for staff working at the facility before allowed to work unsupervised with residents. Document to be submitted by the POC date of 5/24/23.

Allegation investigated: Staff did not prevent a resident from harassing another resident while in care Resident's behavior poses as a risk to other residents while in care Staff make inappropriate comments towards the residents

On 4/27/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Donald Stamets. The reason for the visit was to deliver findings for the allegation sited above. Upon entering the facility, analyst completed electronic screening and sign in. Analyst followed facility's policy and wore a surgical mask. LPA conducted interviews with the Director. Director provided email copies regarding concerns raised regarding R1 and R2 interactions. LPA interviewed one resident. While conducting this investigation, LPA reviewed resident records and conducted extensive interviews. LPA finds that the allegation cited above are Unsubstantiated. Interviews of residents and staff regarding staff not preventing a resident (R2) from harassing another resident (R1)while in care and resident's (R1) behavior poses as a risk to other residents while in care, did not support the allegations. Unsubstantiated The allegations of R1's concerns regarding the behavior of R2 were documented as having been brought to the facility's attention in December 2021. Room changes were explored for both R1 and R2. Escort services were discussed for R1 when they moved throughout the community. Interviews of facility staff found the facility staff believed they provided escort for R1 when requested and that R1 would not request escorts before moving about in the community. Reporting party denies that escort services were provided as agreed. Records review and interviews did not uncover any other reports of R2 behavior with other residents. Regarding staff making inappropriate comments toward residents was also not supported by interviews or records. Given the time between the alleged incidents and the investigation made many of the staff or residents present in December 2021 no longer available during this investigation As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator.the state’s words, verbatim · CDSS document, Apr 27, 2023 · control 25-AS-20221024145711

Type of visit: Case Management - Other

On 4/27/23, Licensing Program Analyst (LPA) Kevin Mknelly, met with Donald Stamets to follow-up on incident report submitted to the regional office on 4/14/23, 4/22/23 and 4/25/23. Upon entering the facility, analyst completed electronic screening and sign in. Analyst followed facility's policy and wore a surgical mask. The report submitted on 4/14/23 was for a resident to resident incident of aggression of R1 toward R2. Records and statement found R1 to have dementia and to be a resident in the memory care section of the facility with R2. There was no prior history reported to LPA of aggressive behavior by R1 toward other residents. The report submitted on 4/22/23 was for a resident to resident incident of aggression of R1 toward R3. Records and statement found R1 to have dementia and to be a resident in the memory care section of the facility with R3. 1:1 caregiver for R1 noted in the 4/14/23 report was not begun until 4/26/23. The report submitted on 4/25/23 was for a loss of money belonging to R4. The money was reportedly delivered to R4 by a family member on 4/20/23 for an upcoming outing. On 4/22/23 the money belonging to R4 was found to be missing. LPA interviewed facility Director, Resident Care coordinator and R4. LPA Observed R1, R2 and R3 to having lunch with care givers present. LPA received the LIC 602 for R1 and the staff schedule for the period of reported incidents. LPA requests the resident profile with resident emergency/ responsible party contacts for R1, R2, R3, R4. As a result of today’s inspection, no deficiencies were found at this time. Report was reviewed with the Director and copy provided.the state’s words, verbatim · CDSS document, Apr 27, 2023

Type of visit: Case Management - Other

On 4/17/23, Licensing Program Analyst (LPA), Kevin Mknelly, conducted a case management visit to follow-up on recent incident reports submitted to the regional office. LPA met with the nurse and explained the reason for the visit. LPA followed the Department's current Covid-19 precautions. LPA complied with facilities masking policy. On 4/13/23, the regional office received an incident report that stated that on 04/03/2023 at 5:50 am. Noc Medication care manager (S1)gave the a new resident (R1) levothyroxine 75 mcg. The resident has an order for levothyroxine 50 mcg, R1 received an additional 25 mcg. Resident (R1) self-manages R1's own medication. R1 suffered no ill effects as a result and R1's physician recommended continue with regular scheduled doses. S1 received an in-service regarding the medication errors. The facility also submitted a incident report regarding a medication issue which occurred on 4/8/23 regarding PRN medication for R2 administered by S1. R2 had an original prescription for half a 5 mg dose of pain medication. During a follow-up visit R1's physician gave a verbal order for a full tab of the same medication. On 4/14/23, R1's physician provided a written order for a full tablet. However, records review found that the facility was in possession of a hospital discharge summary stating a half tab be given for R1's pain on 4/8/23. This summary was not signed by the physician. Report continued... Records review and interviews conducted by LPA on 4/17/23 found that a medication error occurred on 4/3/23 involving R1 and S1, the error was not reported to CCL within 7 days of the occurrence of the 4/3/23 medication error and the facility did not have a signed physician's order for R2's medication given on 4/8/23. As a result of this investigation, LPA finds allegation to be (S) 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 cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Stephanie Jameson . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 17, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 19, 2023

Incidental medical and dental care- (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by records and interviews that On 4/3/23, R1 received the wrong dose of medication. This posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Apr 17, 2023

Plan of correction: Licensee will submit a written plan which addressed corrections to the process of medications taken from the med cart to be delivered to residents have identifying information on the med cup to insure delivery to the corrct resident by the POC date of 4/19/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465 · Plan of correction due date: May 1, 2023

Incidental Medical and dental care- For every ... medication for which the licensee provides assistance there shall be a signed, dated written order from a physician. This requirement was not met based on records and interview that R2 did not have a signed order. This posed a potential risk.the state’s words, verbatim · CDSS document, Apr 17, 2023

Plan of correction: Licensee will submit signed physican's orders for all medication administered to R2 by the POC date of 5/1/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211 · Plan of correction due date: May 1, 2023

Reporting Requirements- (a) (1) A written report shall be submitted to the licensing agency...within seven days ... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met based on records review and interviews which found that a medication error occured on 4/3/23 and was not reported to CCL until 4/13/23. This posed a potential risk to residentthe state’s words, verbatim · CDSS document, Apr 17, 2023

Plan of correction: Licensee will provide documentation of staff training regarding reporting requirements, for those staff authorized to report, to ccl by the POC date of 5/1/23.

Type of visit: Case Management - Other

An office meeting was held on April 14, 2023 at 11:00 PM on a Microsoft Teams Meeting video conferencing system review the Stipulation and Waiver and Order (Stipulation) adopted on March 28, 2023 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period and all current and future residents during probation will be notified. The following were in attendance: Regional Manager Alycia Berryman, Licensing Program Laura Munoz, , Licensing Program Manager, Licesning Program Manager- San Diego-Denise Powell, Licensing Program Analyst Kevin Mknelly and Aegis representatives Ronald Stamets, Ana de la Cerda. Alycia Berryman discussed the purpose and elements of this type of meeting. The Stipulation was reviewed with the Licensee who expressed their understanding. Items discussed at the meeting included, but not limited to: Stipulation contents · Findings · Revocation of License Aegis of Carmichael and Shadowridge- Stayed with Probation conditions · Revocation of Administrator Certification- William Phelps- stayed with probation · Exclusion of Michelle E Connor- stayed with probation · Revocation of Ventura License: discipline with statewide training · Appeals of $10,000 and $15,000 civil penalties denied · Future Application for a license, registration, certification or approval · Tolling of probationary period Report continued... · Violation of Stipulation Term · Completion of probation · Violation of stipulation terms · Completion of probation and future applications · 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 March 28, 2023 · No Oral modification The Licensee/Respondent/Representative stated they would abide by the following: ꞏ Abide by the contents/terms of the Stipulation (submit all documents timely) ꞏ Operate the facility in strict compliance with the regulations and statutes governing the operation of a residential care facility for the elderly. CCLD will do the following: ꞏ Increase monitoring Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. A virtual exit interview was conducted, and a copy of this report was provided via email for a signature. Donald Stamets agreed to return a signed copy to CCLD by COB 4/14/23.the state’s words, verbatim · CDSS document, Apr 14, 2023

Type of visit: Case Management - Other

On 3/23/23, Licensing Program Analyst (LPA), Kevin Mknelly, conducted a case management visit for and incident reported. LPA met with Interim Director and explained the reason for the visit. LPA followed the Department's current Covid-19 precautions and wore a surgical mask while present . Staff were wearing masks. LPA spoke with the Director, Health Services Director and Medication Technician. R1 presented with illness on the morning of 3/15/23. Medical care was called in a timely fashion. R1 was hospitalized for days and returned to the community at baseline. As a result of todays inspection there are no deficiencies cited at this time. Report reviewed with Donald Stamet. Copy of the report provided.the state’s words, verbatim · CDSS document, Mar 23, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michael Hood met with Acting Administrator, Bill Phelps, to conduct a case management visit. The purpose of today's visit is to follow-up on a Metro Fire Annual Inspection conducted at the facility by Sacramento Metropolitan Fire District on 10/12/22. A Metro Fire Annual Inspection report was generated and submitted to the Department on 10/27/2022. The Department reviewed the Annual Inspection report and determined that the facility had violations that are in both CA Fire Codes and Title 22. Today’s visit is to address the issues found in the Annual Inspection report that apply to Title 22. Based on Metro Fire Annual Inspection report, the following Title 22 violations occurred: - Doors to self close and latch should be repaired - Fire extinguisher by room 203 should be serviced Doors that self close and latch have been repaired as of today's inspection. Facility is currently waiting for fire extinguisher servicing company to service extinguisher by room 203. Facility contacted services for extinguisher on 10/28/2022 and company will come to service extinguisher at any time during the week. As a result of today's inspection, per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with Acting Administrator. A copy of this report and appeal rights were provided. The Acting Administrator’s signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Nov 2, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 17, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews conducted, the facility did not esnure that certain fire safety devices were operable, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2022

Plan of correction: Facility is conducting training regarding fire safety malfunction and fire alarm. Doors that self close and latch are repaired. Facility will service fire extinguish. Facility will submit proof of training and proof of serviced fire extinguisher to LPA by POC due date of 11/17/2022.

Allegation investigated: Facility does not have an operational fire alarm system

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Business Office Manager (BOM), Danelle Houle, to deliver findings into the complaint allegation listed above. LPA wore an N-95 mask. Facility staff wore masks while on the premises. During the investigation, LPA conducted interviews and requested documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility does not have an operational fire alarm system ** Report continued on 9099-C ** Substantiated Interview conducted with Administrator indicated that they noticed that fire alarm system wasn't working in July 2022. Administrator stated that they notified the home office that alarm needs to be fixed and a work order was created in July of 2022. Administrator stated that staff were conducting fire watch rounds from July 2022 to October 2022 before Metro Fire took over fire watch. LPA observed documents showing Maintenance Coordinator and NOC shift Med-Tech conducting fire watch before Metro Fire took over fire watch. Administrator stated that the facility is under contract with Matsom Alarm and has the alarm system scheduled to be fixed no later than November 1st, 2022. Interview with staff member S1 indicated that they were made aware of the alarm system being partially inoperable sometime in the Spring of 2022 (February, March, or April). S1 stated that home office was notified at the time system was observed to be partially inoperable and staff were trained on how to use the system in its current condition. S1 stated that a technician working on the fire alarm panel caused half of the system to short out, causing half of over 300 devices not reporting to the main panel. While all over 300 devices will work individually, half will not report the location of the fire or notify local fire department that there is a fire. S1 could not identify which devices were not reporting to main panel or what portions of the facility were affected. S1 stated that fire alarm company used by facility were supposed to replace parts back in Spring of 2022, but system was too old to replace parts. Interviews with Administrator, S1, and staff member S2 indicated that the fire alarm system is still partially inoperable. As of today's inspection on 10/27/2022, the fire alarm system at the facility is still partially inoperable. LPA obtained documents regarding fire alarm system as well as fire watch documents before after and Metro Fire took over fire watch during investigation. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with BOM. A copy of this report and appeal rights were provided. BOM's signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 27, 2022 · control 25-AS-20221013111936

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Oct 28, 2022

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on interviews conducted, the facility did not esnure that they had a completely operatable fire alarm system, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2022

Plan of correction: Facility will submit fire watch logs to department daily until fire alarm system is fixed. Facility will complete a plan for when and how the fire alarm system will be fixed. Facility will submit plan to LPA by POC due date of 10/28/2022.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Business Office Manager (BOM), Danelle Houle, to conduct an inspection. During inspection, it was discovered that the Department did not have any reports from the facility indicating that fire alarm system became partially inoperable from July 2022 to October 2022. Due to facility not supplying the Department with report regarding fire alarm system being partially inoperable, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87211(a)(1)(D) regarding reporting requirements. Deficiencies are listed on 809-D. Exit interview was conducted with BOM. A copy of this report and appeal rights were provided. The BOM’s signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 27, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 28, 2022

87211 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) (…) (D) Any incident which threatens the welfare, safety or health of any resident (…) This requirement is not met as evidenced by: Based on records reviewed, the facility did not esnure that the Department was reported to regarding fire alarm system being partially inoperable, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2022

Plan of correction: Facility will complete a plan regarding reporting requirements to the Department. Facility will submit plan to LPA by POC due date of 10/28/2022.

Type of visit: Case Management - Other

On August 2, 2022, Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced and met with Administrator, Bill Phelps, and explained the purpose of inspection. Prior to initiating today’s inspection, LPAs completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive COVID-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per COVID-19 precautionary measures upon entering the community. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. On February 16, 2021, the Department concluded a complaint investigation which alleged the following: Facility staff failed to provide adequate supervision which resulted in resident (R1) sustaining a fracture, resulting in death. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87705(c)(3)(C): § 87466 Observation of the Resident which states; “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.” Two additional citations were issued following the investigation pertaining to; 1) Violating CCR Title 22 § 87705 ( c )(4) Care of Persons with Dementia which states; “(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional safety and health care needs as identified in his/her current appraisal.”; cont on 809C(1).. 809C(1)...and 2) Violating CCR Title 22 for § 87405 Administrator - Qualifications and Duties (h) which states; “The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, specified in section § 87457, Pre-admission Appraisal, and Reappraisal, as specified in section 87463.” The investigation revealed that on July 18, 2020, staff (S3) indicated they heard a loud crash while on route to replenish needed supplies. S3 found resident (R1) at the base of a four-stair corner landing, face down, with the wheelchair on top of R1, bleeding significantly from their head. Records indicated S3 immediately radioed S1, who subsequently called 9-1-1. Records reviewed indicated that 9-1-1 was contacted at 12:51 a.m. on July 18, 2020, and R1 was subsequently transported to the emergency room. Hospital medical records indicated that R1 was admitted to the emergency room on July 18, 2020 at 1:25 a.m., with a diagnosis of Traumatic Cerebral Intraparenchymal Hematoma, a closed fracture of right zygomatic bone, a subarachnoid hemorrhage, a closed left acetabular fracture closed blow out fracture of the right orbital floor; and R1 was placed on hospice. R1 was scheduled to return to the facility on July 19, 2020, but passed away at the hospital later that day at 6:05 p.m. A review of the facility’s motion sensor records in R1’s room confirmed the alert was activated at 12:23 a.m. and again at 12:31 a.m. on July 18, 2020. It was also confirmed that motion sensor alerts are sent directly to the on-call staff’s pager noting, “MOTION” in a specified room. Records reviewed confirmed that S1 was the only staff working the Assisted Living Unit of the facility on the NOC shift of July 18, 2020. Further, S1 stated during their interview that they did not receive an alert from R1’s motion sensor on the aforementioned date. A review of the pendant response logs during the NOC shift on July 18, 2020, revealed that S1’s pager was functioning properly, and that S1 was responding in a timely manner to pendant alerts. Specifically, a review of the pendant response log revealed that S1 was responding to pendant calls for R2 at 12:02 a.m., R3 at 12:14 a.m., and R4 at 12:21 a.m. S1 did not receive another pendant call until 3:33 a.m. Thus, S1 had approximately twenty-eight minutes to respond to R1’s motion sensor. Records reviewed during the investigation revealed that R1’s physician’s report dated May 15, 2019, indicated a primary diagnosis of dementia, needs “fall supervision,” and is wheelchair bound. Additionally, R1’s care plan dated April 15, 2020, indicated that R1 had a potential for falls, confusion and memory loss related to time and place orientation, poor safety judgment, and evening confusion. cont on 809C(2).. 809C(2).. Interviews conducted with multiple staff from July 2020 to January 2021, revealed that due to R1’s cognitive decline, R1 should have been in the memory care unit. However, according to multiple staff, due to R1 being physically fairly independent, R1 continued to reside on the second floor of the assisted living portion of the facility. Multiple staff specifically stated that R1 was forgetful at times, woke up sometimes at night, and attempted to get into their wheelchair. Staff further stated that R1 was confused about their surroundings, especially at night, and would sometimes ask where their room was. Staff also stated during interviews that R1 became more confused and wandered more after the COVID lockdown and appeared more agitated at night in the weeks preceding their death. On July 17, 2020, the evening prior to R1’s fall down the steps, S2 stated that R1 was reportedly more confused than usual during their shift between 6:00 p.m. and 6:30 p.m., and that R1 went to the wrong room twice, and was found wandering downstairs around 7:45 p.m. Further, interviews with staff S1 and S2 confirmed that these changes were not conveyed by S2 to S1 at shift change, as S2 ended their shift one hour early, at approximately 9:00 p.m. on July 17, 2020. Lastly, the licensee did not ensure that the Administrator provided the necessary services that R1 needed by updating R1’s care plan to reflect changes observed by staff. Based on interviews conducted and documentation reviewed, the licensee did not ensure that observed changes in R1’s condition were addressed or documented in a timely manner. On July 18, 2020, at 12:23 a.m. and 12:31 a.m., R1’s room motion sensor was activated, however, S1 failed to respond to R1’s motion sensor alert, which resulted in R1 sustaining a Traumatic Cerebral Intraparenchymal Hematoma, a closed fracture of right zygomatic bone, a subarachnoid hemorrhage, and a closed left acetabular fracture closed blow out fracture of right orbital floor, which ultimately led to their death. The County Death Certificate listed the immediate cause of death as traumatic brain injury due to a fall from the steps. Due to R1’s increased confusion, forgetfulness, agitation and wandering worsening during the weeks prior to their death, S1’s failure to respond to the motion alert in R1’s room on July 18, 2020, provides sufficient evidence that the facility staff failed to provide the care and supervision required to keep R1 safe, while residing on the second floor. At the time of the case management visit on February 16, 2021, an immediate civil penalty in the amount of $500 was issued, and the license was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety code § 1569.49. cont on 809C(3)... 809C(3)...The Department has concluded an analysis and has determined that a civil penalty is warranted for the death resulting from 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, August 2,, 2022, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 in the amount of $15,000 for a violation that the Department determines resulted in the death of R1. However, since an immediate civil penalty of $500 was issued on February 16, 2021, the amount today will be $14,500. A copy of the LIC 421D was given to Administrator, Bill Phelps, and originals were signed. Exit interview conducted. A copy of the report issued. Appeal Rights provided Administrator Bill Phelps’s signature on this report acknowledges receipt of these rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 2, 2022

Type of visit: Case Management - Other

On August 2, 2022, Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced and met with Bill Phelps, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive COVID-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per COVID-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N 95 mask. On June 25, 2021, the Department concluded a complaint investigation which alleged the following: Resident (R1) fell and sustained brain/head injuries while under care of facility staff. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, section § 87705(c)(3)(C): § 87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (C) Recognizing the effects of medications commonly used to treat the symptoms of dementia. Additionally, the licensee was cited for violating CCR Tile 22 § 87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in section § 87467, Resident Participation in Decision Making and Health and Safety Code §1569.625 Staff training; legislative findings; cont on 809C(1).. 809C(1)..contents (c) The training shall include, but not be limited to, all of the following: (7) Dementia care, including the use and misuse of antipsychotics, the interaction of drugs commonly used by the elderly, and the adverse effects of psychotropic drugs for use in controlling the behavior of persons with dementia. During the complaint investigation a review of R1’s facility file was conducted. File records indicated R1 had 5 falls which occurred on January 13, 2020, April 4, 2020, May 14, 2020, May 23, 2020, and May 26,2020. Specifically, on May 14, 2020, R1 cut the skin on their elbow and was given first aid treatment at the facility; on May 23, 2020, R1 hit their head as a result of a fall and was sent to the ER, and on May 26, 2020, R1 hit their head as a result of a fall and suffered extensive cerebral hemorrhaging and was admitted to the hospital. (According to mayoclinic.org, Intraverbal hemorrhage “cerebral hemorrhage” is defined as a collection of blood within the skull. It's most commonly caused by the rupture of a blood vessel within the brain or from trauma such as a car accident or fall. The blood collection can be within the brain tissue or underneath the skull, pressing on the brain). Multiple caregivers stated to the Department on August 11, 2020, and August 12, 2020, that R1 needed one-on-one care, constant supervision while awake due to wandering, and falling behavior. Interviews with caregivers revealed that R1 had more falls than were documented by facility staff. There is no evidence obtained that facility staff updated R1’s care plans due to R1’s change in condition, specifically due to R1 sustaining multiple falls and being a fall risk. Similarly, there is no evidence from the investigation that the facility took steps to reduce additional falls. In conclusion, there is sufficient evidence that facility staff violated regulations in failing to act on R1’s change in condition and by lack of sufficient care and supervision of R1, which resulted in R1 suffering severe cerebral hemorrhaging from a fall which required medical intervention. Based on records review, the licensee did not ensure that R1’s care plan was updated during the month of May 2020, when it was observed that there was a clear pattern to the frequency and severity of the falls R1 incurred, while taking medications with a side effect warning of dizziness and drowsiness. Moreover, the licensee did not ensure that staff was properly trained in order to care for R1, who had Dementia. Specifically, there was no documentation provided by the facility that staff (S2, S3 and S4) had received the required annual training in understanding the effects of medications used to treat behaviors associated with Dementia and the use, misuse and interaction of antipsychotic drugs. Based on documentation review, these staff had not received this specific training at all or within the last 12 months, as required. cont on 809C(2).. 809C(2)..At the time of the Case Management visit on June 25, 2021, an immediate civil penalty in the amount of $500 was issued, and the license was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of or protracted loss or impairment of 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, August 2, 2022, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount $10,000. However, since an immediate civil penalty of $500 was issued on June 25, 2021, the amount today will be $9,500. A copy of the LIC 421D was given to Administrator, Bill Phelps and originals were signed. Exit interview conducted. Appeal Rights provided. A copy of the report issued. Administrator Bill Phelp’s signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.the state’s words, verbatim · CDSS document, Aug 2, 2022

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

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following the issuance of a Decision and Order on 7/14/2022. LPA met with Bill Phelps, Interim Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community via Accu-Shield system. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA discussed Decision and Order issued on 7/14/22. A copy was not received by the facility. Proof of Service does not indicate a copy was sent to the facility or facility headquarters. LPA printed a copy of the Decision and Order during today's inspection and emailed a copy following the inspection. Interim Administrator confirmed through Business Office Director that individual #7517215841 last worked at the facility on/around October 2020 and was disassociated from the facility on 11/6/2020. There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jul 27, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced at the facility on 6/28/22 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Interim Executive Director, Bill Phelps and Business Office Manager, Danelle Houle, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. Additionally, LPA was screened by facility staff upon entering the facility. LPA and Business Office Manager toured the interior and exterior of the Assisted Living side of the facility. LPA observed all areas to be clean, in good repair and to be odor free and the bathrooms and kitchen to have paper towels, soap, trash cans with lids and Covd posters.. Facility to ensure hand-washing posters are near all sinks, including in the break room. Facility is limiting staff room to 2 staff at a time. Fire extinguishers observed throughout and to have been last serviced on 3/23/2022. LPA observed multiple Covid posters and hand sanitizers throughout and required postings displayed. Discussed vaccination protocols of residents and staff and visitation protocols in place. A second booster clinic to be scheduled in the upcoming months. LPA and Business office Director completed the Infection Control Domain regarding Covid protocols in place. LPA requested a copy of LIC308, LIC500 and current liability insurance be emailed to CCLD by 7/5/2022. There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Administrator. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jun 28, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced at the facility on 6/28/22 to conduct a case management inspection for an incident report (LIC624) submitted for an incident occurring on 6/6/2022. LPA met with Interim Executive Director, Bill Phelps and later Susan Domke, Health and Safety Director and explained the purpose of the visit. Prior to initiating the case management inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. Additionally, LPA was screened by facility staff upon entering the facility. During today's inspection, LPA interviewed, Susan Domke, Health and Safety Director ,Regional Nurse, and staff, Jewell Harrell. in person and Felicidad Ibarra, by phone, LPA reviewed hospital documentation following the incident showing resident (R1) was admitted on 6/6/22 at 7:26 pm and discharged the same day at 9:16 pm with a diagnosis of fall, closed head injury and forehead abrasion. Hospital documentation notes that resident had a unwitnessed ground level fall, was bleeding from the forehead and CT scan showed "no intracranial trauma or acute fracture". Regional Nurse who completed LIC624 confirmed that resident was found outside on the enclosed patio by the caregiver after having an unwitnessed fall and that resident walks regularly in the hallways. Caregiver stated that resident walks around a lot inside, without a walker, and this was the first time she went outside on the patio. Caregiver stated that if the weather is nice, the door will be left open to the patio, encouraging residents to go outside on the patio. Caregiver stated she is not sure how resident fell and staff should provide 1:1 supervision if resident is walking outside. Health and Safety Director stated resident has a diagnosis of Dementia, is currently doing fine with no recent changes in medications and was not eligible for physical therapy due to the level of Dementia. There are no deficiencies being issued today. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jun 28, 2022

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

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to ensure facility is in compliance with Health and Safety Code §1569.38 Posting of licensing reports; disclosure to new residents following the department serving an Accusation on 2/22/2022. LPA met with Donald Stamets, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 Mask. Administrator showed LPA the posted notice dated 3/3/2022 displayed in the lobby. LPA observed the notice to contain the required elements. Administrator and Business Office Director confirmed a letter was sent to residents and resident representatives on 3/3/2022 and to the Ombudsman on 3/4/2022. LPA confirmed with a resident (R1) that he was notified of the pending legal matter. There are no deficiencies being cited today. Exit interview. Copy of report left with Administrator.the state’s words, verbatim · CDSS document, Mar 10, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of (2) incident reports. LPA met with Donald Stamets, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive Covid-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community via Accu-Shield system. . LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA, Administrator and Dulce Carreon, Health Services Director, discussed recent incident reports received for resident (R1) and for resident (R2), as follows, and obtained copies of physician's reports and hospital discharge papers: Resident (R1) fell on 10/2/2021 (4:05 am) and was sent out for medical attention and returned to the facility the same day with antibiotics for a urinary tract infection. R1 was moved to Memory Care unit on/around 10/2/2021 since resident was observed to be wandering more and an updated care plan was written. Resident fell again on 10/9/2021 (3:35 am) as resident is accustomed to waking up and wandering during part of the night and was also acclimating to the new living unit. On both falls, resident was wearing mule clogs and is now wearing sneakers better support his feet . There were no changes in resident's medications following each visit to the emergency room. Resident is doing well currently. Resident (R2) fell on 9/29/2021 and on 10/4/2021 and was using her walker during each fall. Resident was sent out to the emergency room after each fall and returned on 10/1/2021 and on 10/4/2021, respectively, with no changes in medications. Resident was given general fall prevention resources at discharge on 10/4/2021. Resident was a respite resident and has since relocated to the Aegis community she was planning to move to on/around August 2021 but was unable to due to Covid-19. It appears the falls could not have been prevented. There are no deficiencies being issued on this report. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 13, 2021