The Meadows at Country Place

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required – 1 Year inspection on 4/27/23 at 9:00am. LPA met with Junelle Pangilinan, Medication Technician and stated the purpose of today’s visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 34 bedridden clients. The Administrator Certificate expires on 11/19/2024 for Junelle Pangilinan. The facility has an approved hospice waiver for 10 and there is 2 resident using hospice services at this time. LPA interacted with a random number of residents during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed residents participating in group activities using social distancing during this visit. LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry room, knives to be locked, required furniture, and lighting throughout the facility. LPA observed large storage containers outside holding personal care products and decorations to be locked. The temperature inside the facility was measured on the wall thermostat at 70*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 112.9*F which is not less than 105 degrees F (40.5 degrees C) and more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA reviewed records and interviewed 3 staff and 3 resident during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Administrative Responsibility LIC308, Liability Insurance, Personnel Report LIC500, Qualifications of Administrator/Facility Manager-Certificate Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Apr 27, 2023

Allegation investigated: Facility is not providing PPE to staff Facility staff is not serving a good quality of food

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude a complaint investigation on 9/20/22 at 8:30am. LPA met with Rangi Giner and stated the purpose of the visit. LPA observed that Licensee is on premises assisting residents along with staff during this visit. Upon arrival during the visit on 6/23/22, LPA observed the residents to be finishing lunch. The meal consisted of mashed potatoes and gravy, stir fried vegetables, meatloaf, pudding, cole slaw, with choice of lemonade, orange juice, coffee, and hot/cold cocoa. LPA conducted interviews of staff #1 (S1-S2), Resident #1 (R1), and Licensee. LPA requested and received a roster of residents and staff which included contact with information for staff. Unfounded Regarding allegation, “Facility is not providing PPE to staff” S1-S3 stated, the Licensee provides the PPEs to staff, they are not required to purchase their own PPE/masks but they can buy their own if they wish to do so. S1 is the person who replenishes the PPEs to ensure the facility doesn’t run out. S2 and S3 stated that some staff like to purchase their own. There is PPEs locked in storage and some available to be used near the front door. R1, R3, and R4 stated staff wear their masks. On 6/23/22, an unannounced visit, LPA toured the facility and observed staff wearing masks and a stock of PPEs near the front door for staff use. Regarding allegation, “Facility staff is not serving a good quality of food” R1, R3, and R4 stated to LPA the food is good. S1 stated diabetic type foods meaning sugar free are provided to residents who are diabetic, and the facility also provides foods specific to the resident’s culture when they want it. Residents are asked about their meals and preferences for example on how they wish their eggs to be cooked and if they want what’s on the menu for that day. S2 and S3 concurred. The investigation revealed that there was insufficient evidence to substantiate the allegations. Based on interviews, the preponderance of evidence standards has not been met. “This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.” Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 20, 2022 · control 27-AS-20220621111736

Allegation investigated: Facility staff did not following COVID protocols. Illegal eviction

Licensing Program Analyst(s) (LPA) Victoria Brown arrived unannounced on a subsequent visit on 3/28/22 at 10am. This visit is to conclude the investigation of the above mentioned allegations. LPA met with Rangi Giner, Administrator and Junelle Pangilinan, medication Technician and Beatriz Diwata, Medication Technician and stated the purpose of today’s visit. Regarding allegation,"Facility staff did not follow COVID protocols", the investigation revealed that the Administrator was aware of the requirement to continue care for residents with Covid that is stated in the Provider Information Notices (PIN) PIN 21-38-ASC, PIN 21-49-ASC, and PIN 21-50-ASC. The Administrator did not allow R1 to return home once discharged from the hospital due to covid diagnosis and continually going to public places without wearing a mask. Substantiated Regarding allegation,"Illegal eviction" LPA observed that on the Incident report submitted to Community Care Licensing (CCL) on 1/17/22 it indicated that Resident #1 (R1) was sent to the hospital on 1/15/22 for possible fever and shortness of breath. Administrator Gurshahbaz Singh wrote that due to covid diagnosis and frequent visits to public places not wearing a mask during covid-19, resident was taken home by family to quarantine. In addition, Administrator submitted follow-up documentation to CCL regarding the allegations which also stated that R1's doctor was made aware that R1 was not able to be cared for at the facility with the current condition at which time R1 was then discharged to the family. On the same document it states that on 1/23/22, the Administrator had a conference with the family reiterating that R1 had to be cared for in a medical setting even if the hospital states otherwise. Although, the Administrator stated there was no eviction mentioned, the administrator did not allow R1 to return to the facility once discharged from the hospital. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Staff was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Mar 28, 2022 · control 27-AS-20220120163656

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Apr 29, 2022

Additional Personal Rights of Residents in Privately Operated Facilities In addition to the rights listed in Section 87468.1...personal rights:To make choices concerning their daily lives in the facility. This requirement is not met as evidenced by: Administrator/License did not ensure R1 was allowed personal rights option of wearing a mask. Based on previous Administrator confirming resident was not allowed to return to facility due to going to public places not wearing a mask. This possess an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2022

Plan of correction: The current Administrator/Licensee shall submit in writing that all residents personal rights will be upheld at all times. An inservice to be conducted with staff by 4/12/22. To be faxed by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Mar 29, 2022

Eviction The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement is not met as evidenced by: Administrator/License did not ensure R1 was allowed to return when discharged from the hospital. Based on previous Administrator confirming resident was not allowed to return to facility due covid diagnosis and was sent to family home. This possess an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2022

Plan of correction: The current Administrator/Licensee shall submit in writing that all residents when deemed necessary be given an eviction notice with pertinent information included in the notice as per Health and Safety Code and Title 22 Regulations. To be faxed by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on a subsequent visit on 3/28/22 at 10am. This visit is to conclude the investigation of the above mentioned allegations. LPA met with Rangi Giner, Administrator and Junelle Pangilinan, Medication Technician and Beatrice Diwata, Medication Technician and stated the purpose of today’s visit. During the investigation of the complaint 27-AS-20220120163656 regarding an allegation of "Illegal eviction" LPA observed that on the Incident report submitted to Community Care Licensing (CCL) on 1/17/22, Administrator Gurshahbaz Singh wrote that due to covid diagnosis and frequent visits to public places not wearing a mask during covid-19, resident was taken home by family to quarantine. The Administrator stated the same information to R1's doctor and family. The investigation revealed that the administrator wrote the SIR submitted to CCL as if R1 went with family on their own accord. This is deemed as a false statement to the Department that will be cited. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Staff was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Mar 28, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Mar 29, 2022

False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Administrator/License provided an SIR with misleading information to CCL. Based on previous Administrator confirming resident was not allowed to return to facility and was reluctant to state he was denied reentry to the facility. This possess an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2022

Plan of correction: The current Administrator/Licensee shall submit in writing that all statements provided to CCL with be truthful. To be faxed by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required – 1 Year inspection on 3/28/21 at 10:00am. LPA met with Rangi Giner, Administrator and Junelle Pangilinan, medication Technician and Beatrice Diwata, Medication Technician and stated the purpose of today’s visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 34 bedridden clients. The Administrator Certificate expires on 11/19/2022 for Junelle Pangilinan. The facility has an approved hospice waiver for 10 and there is 1 resident using hospice services at this time. LPA interacted with a random number of residents during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed residents participating in group activities using social distancing during this visit. LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry room, knives to be locked, required furniture, and lighting throughout the facility. LPA observed large storage containers outside holding personal care products and decorations to be locked. The temperature inside the facility was measured on the wall thermostat at 70*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 127.8*F which is not less than 105 degrees F (40.5 degrees C) and more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed hot water temperature to be too high in the bathroom and 2 resident rooms which will be cited during this visit. LPA observed the centrally stored medications area to be locked and inaccessible to clients. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Administrative Responsibility LIC308, Liability Insurance, Personnel Report LIC500, Qualifications of Administrator/Facility Manager-Certificate Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Staff was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Mar 28, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Mar 29, 2022

Maintenance and Operation Water supplies and plumbing fixtures shall be maintained as follows:Faucets used by residents for personal care...attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: License did not ensure the water temperature was within the required range of 105-120*F Based on LPA measured the water temperature in the bathroom, and 2 resident rooms which all read above the acceptible range of 120*F. This possess an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2022