Virginia Denise Country Home

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a case management visit. LPAs met with Administrator, Aileen Fermo, and explained the purpose of the visit. LPAs and Administrator discussed the importance of reporting requirement with the Department. LPAs explained the Department has not received LIC 624A Death Report for R1. LPAs explained it is Licensee's responsibility to provide a written report within seven (7) days of the occurrence. Administrator stated Alta California Regional Center (ACRC) representative provided the requested documents. LPA Yang stated she was unable to confirm the following as LPA Yang attempted contact with ACRC on 10/2/2023 and 10/4/2023 but was unsuccessful. Additionally, LPA Yang did not receive any documents via email as requested. As a result of today's visit, deficiencies was cited. Please see LIC 809-D. Exit interview concluded, a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Oct 4, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Oct 4, 2023

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) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement is not met as evidenced by: Based on interview and file review, Licensee did not comply with the section cited above as LPA Yang did not receive the LIC 624A for R1 as requested during a visit conducted on 9/22/2023, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Licensee is to submit LIC 624A Death Report for R1 to LPA Yang via email by close of business 5PM on Wednesday October 4, 2023.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived to the facility to conduct a case management visit regarding an incident report the Department received. LPAs met with Administrator, Aileen Fermo-Cantor, who arrived to the facility shortly after LPAs. LPAs and Administrator discussed the received special incident report regarding an incident that occurred on 9/20/2023 when R1 was hospitalized after R1 collapsed on the floor. Administrator provided LPAs time of when emergency medical services was contacted. LPAs and Administrator conducted a tour of R1's room, and additionally, LPAs conducted a review of R1's files. At this time, LPAs requested Administrator to submit a copy of LIC 500, R1's 2022-2023 Individual Program Plan, R1's Behavioral Intervention Progress Report, Physician's Report For Resident Care Facilities For the Elderly, Admission Agreement, R1's list of medication, R1's special incident report and R1's death report to be emailed to LPA Yang by close of business Friday 09/22/2023. LPA Yang offered to take R1's file to create copies as LPAs observed Administrator to be in distress but Administrator informed LPA she will do it as she is not aware Licensing Department can remove files from the facility. LPAs provided Administrator a copy of California Code Regulation 87506 Resident Records. Result of today's visit, no deficiencies cited as incident is under review. Exit interview, a copy of report was provided.the state’s words, verbatim · CDSS document, Sep 22, 2023

Type of visit: Required - 1 Year

On July 26, 2023 at 12:45pm, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct an annual inspection. LPA met with Aileen Fermo, Licensee, and advised her the reason for the visit. The Administrator's Certificate is current and expires October 2025. LPA and Aileen completed the Infectious Control questionnaire with no issues or advisories. The Infectious Control Plan is currently in affect. LPA and Aileen toured the home. There are no bodies of water on the premises. The smoke alarm was working. The Medication Administration Record was viewed and found to be completed. The facility's temperature was 75 degrees. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. There’s appropriate lighting throughout the facility. Living room, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be enough and in good repair. Resident bedrooms and bathrooms were toured. To continue see 809-C... Bedrooms had all the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer were present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible. First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. This facility sits on 2 acres and the backyard is currently being landscaped. There’s a centralized storage area for resident’s medication. Medication cabinet was locked. The facility Medication Administration Record was reviewed as well as the dispensing log and was complete and current. Staff records reviewed indicated current First Aid & CPR certificates. Facility is conducting staff training as required. LPA reviewed 2 client files. Files had the the proper updated documents in them. Because 2 clients were in Day Program, there were not able to be interviewed. The other 2 clients were not able to be interviewed due to the lack of understanding of what's being asked. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed. ****The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than August 25, 2023.******* A copy of this report was given to Aileen.the state’s words, verbatim · CDSS document, Jul 26, 2023

Type of visit: Required - 1 Year

On May 25, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct an annual inspection. LPA met with Aileen Fermo, Licensee, and advised her the reason for the visit. Prior to 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. LPA and Aileen completed the Infectious Control questionnaire with no issues or advisories. LPA and Aileen toured the home. There are no bodies of water on the premises. The smoke alarm was working. The Medication Administration Record was viewed and found to be completed. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 108 degrees F, which is within the allowed range of 105-120 degrees. There’s appropriate lighting throughout the facility. Living room, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be enough and in good repair. Resident bedrooms and bathrooms were toured. To continue see 809-C... Bedrooms had all the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer were present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible. First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards. There’s a centralized storage area for resident’s medication. Medication cabinet was locked. The facility Medication Administration Record was reviewed as well as the dispensing log and was complete and current. Staff records reviewed indicated current First Aid & CPR certificates. Facility is conducting staff training as required. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed. The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than June 25, 2022. An exit interview was conducted, and a copy of this report was given to Aileenthe state’s words, verbatim · CDSS document, May 25, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 07/16/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator Aileen Fermo 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 facility and 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. LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathrooms, laundry room, garage, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain together and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at facility. Administrator to send in LIC 808 - Mitigation Plan and copy of current liability insurance to Community Care Licensing by 07/23/2021.the state’s words, verbatim · CDSS document, Jul 16, 2021

The state marks this report as 4 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.