Sunrise Assisted Living of Carmichael

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 7/6/23 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 to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 6 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 checked and water maintained in required range. Stairwells have required evac chair. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. LPA reviewed resident files and staff files. 6 Resident files reviewed are complete and current for documents checked. 7 Staff files reviewed were complete for documents checked. LPA received a copy of liability insurance. As a result of this inspection, no deficiencies are noted. Report reviewed with Tania Langland. Copy of this report.the state’s words, verbatim · CDSS document, Jul 6, 2023

Allegation investigated: Resident sustained unexplained injuries while in care

On 6/16/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Tania Langland to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. The investigation found that on 3/12/23, and altercation occurred between R1 and R2 in the memory care wing. Statements found that caregivers were not presnet at the onset of the altercation but responded when residents were heard yelling at one another. When staff arrived R1 and R2 were observed to hit each other. Staff reported R2 hit R1 in the shoulder. Residents were seperated and assessed to have no known injuries at that time. Increased supervision was put in place. At the time of the event, R1 and R2's responsible parties were not notified nor was a report submitted to licensing as required. Family of R1 did not observe injuries to R1 on 3/15/23. On 3/17/23, R1 was observed to have bruising to wrists, upper arms and swelling to a finger. As no other event was witnessed for R1 to .have received those injuries and the the shoulder bruising is consistent with observations of the incident. Substantiated 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 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Tania Langland . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 16, 2023 · control 59-AS-20230328144325

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 16, 2023

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(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 ... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met based on the incident involoving R1 and R2 was a threat to their welfare and was not reported as required. This posed a potential resik to residents.the state’s words, verbatim · CDSS document, Jun 16, 2023

Plan of correction: Licensee investigated the incident, has since done staff retraining of reporting requirements and updated residents care plans for thos involved. No further plan of correction needed at this time.

Allegation investigated: Staff do not assist resident with hearing aids.

On 6/16/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Director/ Administrator,Tania Langland, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Investigation found that on a unspecified date, staff were to have assisted R1 with weekly hearing aid battery replacement that was not done when it was discovered at a Dr. appointment that hearing aids were not working due to dead battery. This was substantiated by staff who were familiar with the event. Since the event, measures have been and continue to be in place to ensure that the incident is not repeated. LPA observation during several visits are that R1 is currently provided the assistance needed for their identified needs. 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 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Tania Langland . Copy of this report and appeal rights provided. Substantiated Inspections during this investigation found the facility to be free of hazards. R1 was found to be a fall risk and has experienced falls. However, the reported falls were not attributed to staff failure to manage the residents environment to be a reason for the falls. 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, Jun 16, 2023 · control 25-AS-20230217081106

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(3) · Plan of correction due date: Jun 16, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. ... by compliance with the following (3) When residents require prosthetic devices, vision and hearing aids, the staff shall be familiar with the use of these devices, and shall assist such persons with their utilization as needed. use of these devices, and shall assist such persons with their utilization as needed. This requirement was not met as evidenced by R1's hearing aid batteries not managed. This possed a potential risk to the residentthe state’s words, verbatim · CDSS document, Jun 16, 2023

Plan of correction: Licensee has put measures in place to remedy the situation. No further plan of correction needed at this time.

Allegation investigated: Staff sexually abused a resident Staff physically abused a resident Staff refused to seek medical attention for resident

On 6/16/23, Licensing Program Analyst (LPA) Kevin Mknelly LPA Mknelly arrived and met with Administrator to deliver investigation findings. The department reviewed staff records, facility records, hospital records, police report and conducted interviews. The department finds that facility met Tittle 22 requirements. It was reported that R1 was experiencing pain and discomfort. The licensee had reported the incident to R1's physician. Care and supervision was provided as directed. When abuse was reported, R1 was seen and examined by medical professionals with no signs of injury or abuse found. The incident was also self-reported to licensing. Local police investigated and found R1 unable to state concerns. The department found that statememts attributed to R1 as R1's allegations of abuse were not consistent with other diagnosis of severe limitations to articulate consistent of historically accurate events. Unfounded This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Jun 16, 2023 · control 59-AS-20230307143144

Allegation investigated: Staff hit resident while in care. Staff is handling resident in a rough manner.

On 10/18/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced and met with Health Care Director, Christina Bond and explained the purpose of the visit was to deliver findings for the allegations cited above. LPA wore a surgical mask and was screened by facility upon entry. Regarding staff hitting resident while in care and staff is handling resident in a rough manner, LPAs interviewed staff and all staff denied hitting and/or handling resident in a rough manner. LPA interviewed R1 who denied staff giving her bruises, hitting and/or handling R1 in a rough manner. During the investigation, LPAs conducted interview with (1) reporting party, (11) staff, (1) resident, and (2) family members. LPA also reviewed R1’s resident records and home health reports. Based on interviews and record reviews, LPA finds allegation to be (U) UNFOUNDED - An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview with Health Care Director and a copy of the report and appeal rights was provided. Unfoundedthe state’s words, verbatim · CDSS document, Oct 18, 2022 · control 25-AS-20220801132459

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 8/30/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management regarding a serious injury incident report the Department on 8/23/2022. LPA Yang met with Executive Director, Lyndee Whaley, Terrence Club Coordinator, Rachel West and Resident Care Director, Christina Bond and explained the purpose of the visit. Prior to initiating the visit, 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. LPA completed a facility risk assessment upon arrival. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. On 8/19/2022, R1 was reported to have fallen when attempting to self transfer to the bathroom. R1 was found on the floor and 911 was called. R1 was reported to be in severe pain and was transported to UC Davis Medical Center. R1 was discharged from the hospital and returned to the community later that day. LPA interviewed with (4) staff and obtained copies of the visitor log of August 19, 2022 and August 20,2022, R1's resident profile, UC Davis After Visit Summary, R1's Death Report and Home Health Visit Report. As a result of today’s inspection, no deficiencies were noted. LPA reviewed the report with Executive Director and a copy was provided and left at the facility.the state’s words, verbatim · CDSS document, Aug 30, 2022

Type of visit: Required - 1 Year

On 7/22/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual. LPA met with Cynthia Bazin, Executive Director, and explained purpose of inspection. Executive Director notified Maintenance Coordinator, Amir, who joined the inspection. Before today's inspection, LPA completed required COVID-19 testing protocols and completed daily assessment. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. The facility is licensed for (66) residents and has a hospice waiver for (15). There are (5) residents currently on hospice. LPA, Maintenance Coordinator and Executive Director toured the interior of the facility including the Terrace Club Unit, Reminiscence Unit, laundry room, private resident rooms, shared residents room, guest restrooms, salon, kitchen, and common areas including the lobby area. In areas toured, LPA observed the facility to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. LPA observed PPE supplies to be available throughout the facility. LPA observed paper towels, foam soap and hand washing signs in restrooms. Fire extinguishers last serviced 4/21/2022. LPA observed all staff to be wearing surgical masks. LPA observed a current Administrator Certificate posted. LPA observed emergency food kits to be available in the kitchen, LPA observed 300 gallons of emergency water in stock. LPA observed residents doing activities in the activity room in the Terrace Club level and Reminiscence Unit level. LPA requested an updated copy current liability insurance during today's inspection by 7/29/2022. There were no deficiencies observed during today's inspection. Exit interview. Copy of report left at facility.the state’s words, verbatim · CDSS document, Jul 22, 2022

Allegation investigated: Resident sustained pressure injuries while in care Emergency exits are blocked Facility is retaining a resident that needs a higher level of care

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/21/22 to deliver complaint findings. LPA met with Executive Director (ED) and explained the purpose of the visit. Prior to initiating the complaint visit, 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. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. The department reviewed client/resident records and conducted extensive interviews. The department finds that the allegations cited above are substantiated. Records reviewed and interviews conducted found that R1 sustained pressure injuries while in care and that between 11/23/21 and 12/17/21, Home Health notes recorded R1 to have a Stage III pressure injury Substantiated which continued to be treated at the facility. On 3/16/22, LPA Mknelly interviewed the Executive Director (ED). In the interview, ED acknowledged that she became aware that R1 was retained in the facility with a Stage III pressure injury. In ED’s statement, they became aware when reviewing notes while the facility nurse was absent. Reported by ED, RN was unaware that Stage III pressure injuries are a prohibited condition. While it is documented that R1 experienced pressure injuries that pressure injuries that worsened during the time noted, LPA did not find that the worsening condition from 11/23-12/17/21 was due to a lack of care. The investigation also found that in photographs provided to LPA from a party who was present at the facility, that on 1/6/22, 11:21 AM, 2/2/22 at 10:58 am, and 2/6/22 at 11:13 am, the exit adjacent to room 208 from Reminiscence was blocked by a loveseat. LPA conducted an interview (4/5/22) with a staff who recently quit working at the facility who stated that the use of furniture to block wandering residents from attempting to exit while staffing was low happened “all the time” and they suggested LPA conduct a weekend visit during the NOC shift as it continues. LPA interviewed other staff who had worked NOC shift or AM shifts who denied knowledge to this practice. The overnight staff who worked the shifts preceding the photographs did not respond to two LPA attempted phone interviews. Photographs and a supporting statement met the preponderance of evidence. 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 9099-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 ED . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 21, 2022 · control 25-AS-20220105153033

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Apr 25, 2022

Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by records and statements that R1 developed Stage III pressure injury and was retained at the facility. This posed an immediate health risk to R1.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: This issue was responded to at the time it was discovered by the ED. Licensee will submit proof of inservice to RCD, RN and the wellness team clarifying prohibitted health conditions by the POC date of 4/25/22

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: May 5, 2022

Personal Accommodations and Services (d) (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by photographs and statements that an exit was obstructed on at least three occasions This posed a potential risk to resident’s health safety and personal rights.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: Submit proof of inservice training regarding removing exit obstructions timely if observed and establish routine monitoring of overall safety hazards monitoring in the facility by the POC date of 5/5/22.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/21/22 for a Case Management visit. LPA met with Executive Director (ED) and explained the purpose of the visit. Prior to initiating the complaint visit, 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. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. The purpose of this inspection was to follow-up on incident reports received by the department. On 4/1/22, R1 was reported to have fallen when attempting to self transfer in the bathroom. Resident was properly supervised and assisted with care. The fall occurred due to the resident's not following transfer assistance recommendations. On 4/14/22, R2, was found to have developed a stage II pressure injury. LPA found that necessary care and supervision was provided to R2. LPA advised a more formal documentation system for resident skin care checks be instituted and maintained when applicable for residents of concern. On 4/16/22, R2 who has a history of GI issues, developed a GI bleed. Medical care was provided timely. LPA advised that resident conditions be identified for all residents to ensure staff notify managers for changes of condition promptly. As a result of today’s inspection, no deficiencies were noted. LPA reviewed the report with ED and provided a copythe state’s words, verbatim · CDSS document, Apr 21, 2022

Allegation investigated: Staff physically assaulted the resident in care. Staff did not report properly report incident to responsible party.

On 4/13/22, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with clinical staff. Prior to initiating the complaint visit, 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. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened with temperature at the facility. The department conducted records review and extensive interviews. The department is unable to find and or meet the preponderance, per policy. Report continued Unsubstantiated The investigation found that On 09-05-2021 at approximately 0600 hours, S1 and R1 were in the restroom at the facility. R1 allegedly became violent and started attacking S1. S1 attempted to leave the restroom, when R1 suddenly grabbed S1’s arm and pinned it behind S1’s back. According to S1, S1 repeatedly asked R1 to release them but R1 refused. S1 had to forcibly pull her hand free from R1 but in doing so, R1 lost their balance and stumbled backwards. Initially, S1 believed R1 to be okay but then S1 noticed blood on R1’s head. S1 called for help but received no response. S1 walked R1 to the Med-Tech room and asked for help. R1 was transported to an area hospital. Per medical records from the area Emergency Room, R1 sustained a 2cm laceration to their head and was given staples as treatment. R1 was release back to the facility on the same day. Per facility staff and R1’s medical history, R1 has a diagnosis of dementia. Records and interviews found R1 has a history of becoming confused and in her confusion, R1, at times, becomes physically and verbally aggressive towards residents or staff. The department interviewed several staff members. All staff essentially provided the same story. R1 has been physically aggressive towards them and other residents. The staff that has worked with S1 stated she is professional and really cares for residents. No staff member interviewed has witnessed S1 become aggressive towards residents. No staff could comment on the incidents of the fall as they were not present. Staff stated they do not believe S1 pushed R1. An attempt was made to interview R1 who was unable to stay engaged in the interview. Multiple attempts were made to interview S1 however S1 had resigned and did not return calls. The facility staff informed PoA, R1 sustained an unwitnessed fall on 9/5/21. On the evening of 9/5/21, facility notes that staff spoke with PoA at 6:52 PM to update PoA of R1’s status. Report continued. Care staff reported to LPA that they recall that R1 was in a physical altercation with S1 on 9/5/21 that resulted in R1’s fall and injury. Staff could not recall the exact day and time that PoA was informed. Facility Resident care coordinator told investigator that on 9/5/21, they informed on-floor supervisor of R1’s fall. Supervisor notified R1’s family of the fall and called an ambulance. Community Care Licensing received an incident report on describing R1’s fall as unwitnessed. On 3/17/22, R1’s PoA told investigator that on 9-05-2021 at approximately 0600 hours she received a call from the facility stating R1 was being sent to the hospital for an unwitnessed fall. PoA stated she does not recall who she spoke with on the phone. The staff member who called PoA stated staff turned the corner and witnessed R1 standing outside her bedroom with blood from her head. The staff member asked R1 what happened but due to R1’s dementia, R1 was unable to tell her what happened. The staff member stated she believes R1 could have fallen in her bathroom. PoA further reported that she did not get a call from the facility’s Executive Director until 9-16-2021 to tell her what the more detailed description of S1 and R1 having a physical struggle when R1 fell and sustained an injury. LPA Mknelly received information from facility staff who had spoken with PoA between 9/5/21 and 9/16/22 that they believe PoA knew that S1 was with R1 at the time of the fall and that there was an investigation to the incident. However, Administrator presented LPA with a note that on 9/13/21 they had a “follow-up call” with PoA with the results of their internal 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 13, 2022 · control 25-AS-20211005083639

Allegation investigated: -Facility staff failed to report resident's change in condition to responsible party. -Facility staff did not seek timely medical attention for a resident in care. -Resident sustained an injury due to an unwitnessed fall. -Resident was admitted to facility without responsible party's consent. -Resident was moved to another room without responsible party's consent.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Davina Barker, to deliver findings into the above listed allegations. LPA wore an N95 mask and was screened upon entry in the care home. All staff wore masks in the care home. There are no COVID positive cases at the facility. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. *************************************************Continued on LIC9099-C**************************************************** Substantiated Facility staff failed to report resident's change in condition to responsible party. Incident reports indicate that the conservator was notified of falls that took place on 12/21/20 and 12/22/20. Progress notes for 12/21/20, 12/22/20 and 1/28/21 indicate that the conservator was notified of resident (R1’s) falls. Progress notes indicate that a meeting was held on 2/11/21 regarding a possible change in R1’s condition and that there was concern of a potential UTI. On 3/9/21, the facility was informed that the resident had a positive UTI lab result and was prescribed a new medication. According to the progress notes and interview with the Resident Care Coordinator, the conservator was contacted via email on 3/4/21, 3/9/21, 3/10/21, and 3/11/21 regarding an updated care plan after being re-evaluated by facility. The updated care plan does not specify that the resident had a positive UTI. The interviews, emails provided by facility, and progress notes revealed that the conservator was not notified of the resident’s positive UTI lab results. Facility staff did not seek timely medical attention for a resident in care. Progress notes indicate that a telephone conference was held with the conservator on 2/11/21 regarding a possible change in R1's condition and the concern of a potential UTI. Progress notes from 2/12/21 indicate that R1 was seen by a physician, a urinalysis (UA) was ordered, and the UA order was to be faxed to the facility. Progress notes from 2/22/21 notate communication with the conservator and that the conservator wanted to follow-up on UA testing. Facility informed conservator that they did not yet receive the UA order. Progress notes on 2/25/21 indicate that R1 had a doctor’s appointment and facility followed-up on the UA order. On 2/25/21, facility received documentation from All Inclusive Medical Services (AIMS), which specifies "UA culture if indicated". Progress notes from 2/26/21 indicate that a nurse from the facility contacted AIMS to follow-up on the UA order. Progress notes from 3/1/21 indicate that the facility received a new order for UA with culture if indicated and the conservator was notified. According to progress notes dated 3/2/21, the conservator picked up the UA sample from the facility on 3/2/21. The facility had several gaps of communication with the physician and UA clinic between 2/12/21-3/2/21 regarding the UA order. ****************************************************Continued on LIC9099-C************************************************* Resident sustained an injury due to an unwitnessed fall. On 12/21/20, R1 had an unwitnessed fall in one of the hallways of the facility and sustained a pelvic fracture. R1 has a history of fainting spells and facility staff utilize a documentation survey report to indicate when staff assist with R1's daily living needs. According to the documentation survey reports dated December 2020-April 2021, facility staff provided assistance with mobility and any transfer needs during all shifts. Facility staff also contacted emergency services in a timely manner after the fall on 12/21/20 and R1 received medical care. Although the allegation is Substantiated, no deficiencies are being cited for this allegation as the facility followed the needs and services plan and also ensured R1 received appropriate medical attention. Resident was admitted to facility without responsible party's consent. R1 was admitted to the facility on 6/29/20 and family member signed the admission agreement for R1's admission. R1's admission agreement is missing a signature from R1's conservator. R1's conservator signed R1's Care Plan dated 7/1/20, which was 2 days following the admission of R1 to the facility. The facility does not have any documentation indicating that the conservator provided written consent for admission of R1. Conservator documentation indicates "it is ordered that the conservator of the person is authorized to place the conservatee in a secured-perimeter residential care facility for the elderly". The conservator was not included in the admission of R1. Resident was moved to another room without responsible party's consent. Progress notes from 3/12/21 indicate that the facility contacted the conservator via email to inform them that the facility was to begin day programming for R1 in the Reminiscence (REM) neighborhood. Progress notes from 3/26/21 indicate that the facility staff spoke with the conservator to report that they are ready to move R1 to the REM neighborhood. The facility moved R1 to the REM neighborhood on 4/2/21. R1 has a diagnosis of Dementia and conservator of care. A 30-day written notice is required for any room changes unless the resident agrees to the room change. R1's conservator would be responsible for agreeing to any room changes for R1. The facility did not have any documentation indicating that a 30-day written notice was provided to R1's conservator regarding R1 moving to a new room on the second floor in REM. Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D. An exit interview was conducted with the Executive Director and a copy of this report. Appeal rights were provided. Facility staff failed to observe resident's change in condition Progress notes indicate that a telephone conference was held with the conservator on 2/11/21 regarding potential elimination of resident (R1) utilizing 1:1 companionship care from an outside resource. Progress notes for 2/11/21 indicate that there was concern with R1 having a potential change in condition that was recognized by the 1:1 companion. Progress Notes indicate that, during the phone conference on 2/11/21, there was discussion regarding the conservator being informed by the 1:1 companion that R1 was agitated in the mornings, which was not R1’s baseline. However, facility staff were not informed by the 1:1 companion of R1’s behavior. Progress notes indicate that R1 can get agitated and refuse assistance from staff frequently. The day after the telephone conference conducted on 2/11/21, R1 was seen by a physician regarding a potential UTI. According to interviews with the Executive Director and Residential Care Coordinator, R1 has a history of UTIs. There were no notations in any of R1’s progress notes indicating that facility staff had noticed a change in R1’s condition. Based on interviews conducted and records reviewed, 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. No deficiencies are being cited during this visit. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 4, 2021 · control 25-AS-20210409155333

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 5, 2021

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure resident received timely medical care for UTI, as the initial concern was 2/11/21 and UA sample was not collected until 3/2/21, which posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2021

Plan of correction: Administrator agrees to create a plan to ensure that, when a resident has a change in condition, the facility will arrange or assist in arranging appropriate medical care. Administrator shall submit to LPA by the POC due date of 8/5/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(1) · Plan of correction due date: Aug 18, 2021

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. This requirement is not met as evidenced by: Based on records reviewed and interviews, the facility did not ensure resident's conservator was informed of change in condition, which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2021

Plan of correction: Administrator agrees to submit a plan to ensure that, when a resident has a change in condition, all appropriate parties are informed. Administrator will also conduct a staff training regarding when a resident has a change in condition and provide LPA signatures of staff that received training. Administrator shall submit to LPA by the POC due date of 8/18/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(l)(4)(A) · Plan of correction due date: Aug 18, 2021

87705 Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (4) The licensee shall maintain either of the following documents in the resident's record at the facility: (A) The conservator's written consent for admission for each resident who has been conserved under the Probate Code… This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that the conservator provided written consent for admission of R1, which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2021

Plan of correction: Administrator agrees to create a plan to ensure that, when a resident is conserved, the facility receives written consent from the conservator prior to admission of the resident. Administrator shall submit to LPA by the POC due date of 8/18/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(16) · Plan of correction due date: Aug 18, 2021

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (16) To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that the conservator was provided a written 30-day notice for the room change of R1, which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2021

Plan of correction: Administrator agrees to create a plan to ensure that, when a resident is conserved, the facility will provide a 30-day written notice if a resident is changing rooms or has conservator sign of form of consent. Administrator shall submit to LPA by the POC due date of 8/18/21.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Praveen Singh arrived at the facility unannounced to conduct a Required 1- Year Inspection utilizing the infection control domain. LPA met with Executive Director Davina Barker (ED), 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: surgical mask. Additionally, LPA was screened by facility staff upon entering the facility. LPA and ED toured facility together to ensure health and safety of residents in care. Areas toured included but were not limited to: Second Floor - seven (7) Life Skill Stations/common areas, dining area, two (2) resident bedrooms and bathrooms, and patio; First Floor - five (5) common areas, two (2) resident bedrooms and bathrooms, kitchen, dining area, and patio. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and ED completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jul 20, 2021