Clara Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 6/29/23 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and four (4) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 115.6 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke detectors and carbon monoxide detector are hardwired and operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed three resident files and also reviewed two staff files. Facility will email a current copy of certificate of liability insurance to LPA. Administrator has a current administrator certificate #6032658740 with an expiration date of 10/1/2024. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Jun 29, 2023

Allegation investigated: Facility staff are not following residents' dietary restrictions Facility is not providing transportation for residents' medical appointments Facility issued an unlawful eviction

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Okki Kim, to to deliver findings regarding the complaint allegations listed above. During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility staff are not following residents' dietary restrictions ** Report continued on 9099-C ** Substantiated Allegation: Facility is not providing transportation for residents' medical appointments Administrator stated that Anthem with Blue Cross was responsible for providing transportation to R1's medical appointments. Administrator stated that Anthem was not operating properly during COVID-19 pandemic and Licensee had to drive R1 to dialysis appointments, but Licensee could not personally drive R1 to all of their appointments. R1's family wanted facility to arrange an Uber ride for R1. Administrator stated that an Uber driver drove R1 to the wrong location. Police were contacted but Uber driver came back and returned resident to facility. Administrator stated that they told R1's family that they need licensed transportation for R1 and if the family wanted R1 to take an Uber, then the family is responsible to arrange an Uber for R1. Administrator stated that they eventually were able to obtain a better transportation company with Blue Cross. Administrator stated that, if R1's transportation did not show up to the facility for their appointment, they would contact Blue Cross and assign a different company to transport the resident. Administrator stated that R1 would miss their window to receive dialysis if transportation did not show up to pick up resident. Administrator stated that R1 missed their appointment a couple times because of either no transportation or R1 refusing dialysis appointments. LPA reviewed text messages sent to relevant party authored by Administrator indicating the following: “Our suggestion is to research for a skilled nursing facility that can accommodate [R1’s] special needs as well as transportation. There are many facility that have their own transportation such as small minivans and small buses. It seems that transportation will always be a problem. We cannot continue to have day after day of these frustrating issues that cannot be resolved.” LPA reviewed R1’s Admission Agreement, which states the facility should provide basic services that include “transportation – we provide transportation to meet health needs within a 10 mile radius at least 4 times per month.” S1 stated that resident (R2) had been trying to go to the dentist during the summer of 2022 for over a three month period. S1 stated that R2 had not been able to get transportation to see the dentist and the Administrator and Licensee were not at the facility to assist. S1 stated that they were unable to assist with transportation as they were the only care staff at the facility when transportation was needed. ** Report continued on 9099-C ** Interviews with relevant parties, staff members S1 and S2, and Administrator indicated that R1 would open the facility’s refrigerator at night and eat items that may not fit with R1’s special diet. A review of R1’s documentation indicated the following dietary restrictions: Physician’s Report for RFCE (LIC 602A) for R1 dated 7/22/2022 states R1 has a special diet “pureed,” LIC 602A for R1 dated 4/8/2022 states R1 has a special diet “chopped meats level 3, ground vegetables, fluid restriction, thick liquids,” LIC 602A for R1 dated 7/15/2020 states R1 has a special diet “renal diet, soft,” LIC 602A for R1 dated 5/21/2018 states R1 has a special diet “renal.” 30-day eviction notice for R1 sent to relevant party authored by Administrator states the following: “my caregivers are not professional dietitians. Although we try to keep in mind what constitutes a renal diet, posting on the board what foods are prohibited, it is difficult for them to keep track considering the multitude of tasks and dietary restrictions each individual has. We are more than open to your corrections and recommendations but I ask that you are a little more understanding of my caregivers and do not blame them for such mistakes. Due to [R1’s] condition, I believe that [R1] would benefit from being placed into a different facility that can provide [them] supervision for [their] breathing troubles and a dietitian to manage [their] dietary needs.” LPA reviewed R1’s Admission Agreement, which states the facility should provide basic services which include “food services, to include 3 nutritious meals daily and snacks, special diets if prescribed by a doctor.” Interview with Administrator indicated that there are currently no residents at the facility that have dietary restrictions. Interview with S1 indicated that R1 is the only resident who had dietary restrictions. S1 stated that R1 would help themselves to food items in the refrigerator all the time. S1 wanted to lock the food and facility was able to obtain a doctor's order on 7/14/2022 to lock food away from R1. However, R1 was already declining by the time that doctor's order for R1 was obtained. S1 stated that R1 broke into the refrigerator until doctor's order was obtained. S1 stated that R1's behavior of helping themselves to food items in the refrigerator stopped after obtaining doctor's order. ** Report continued on 9099-C ** Interview with relevant party indicated that Mercy Hospice representatives did not document any concerns regarding resident (R1’s) oxygen use at the facility. Interview indicated that Mercy Hospice staff arrived at the facility to provide care for R1 multiple times a day to ensure oxygen was used properly. Interview indicated that Mercy Hospice documented that, on 7/29/2022, R1 was experiencing low oxygen saturation but oxygen was on and working properly when hospice staff arrived at the facility. Interview indicated that R1 started oxygen via nasal canula on 7/25/2022. Interview indicated that canula can come off easily when residents using oxygen are uncomfortable. LPA observed oxygen signs posted at the facility for residents using oxygen, including R1, R2, and R7. Allegation: Facility staff does not provide incontinence care Interview with staff member S2 and Administrator indicated that R1 could manage their own incontinence needs prior to being placed on hospice. Interviews with staff member S1, Administrator, Licensee, and relevant party indicated that staff attempted to provide incontinence care services to R1 while family was at the facility and family refused care staff to provide care to R1. Interview with relevant party indicated R1 was placed on hospice services on 7/21/2022 and that Mercy Hospice did not document any observations of R1 being soiled when hospice staff arrived at the facility to provide care to R1. A review of R1’s documentation indicated the following incontinence needs: Preplacement Appraisal Information (LIC 603) dated 8/25/2018 indicated that R1 did not require assistance with toileting. Physician’s Report for RFCE (LIC 602A) for R1 dated 5/21/2018 states that R1 is able to care for own toileting needs. LIC 602A for R1 dated 4/08/2022, prior to going on hospice services, states R1 is able to care for own toileting needs. LIC 602A for R1 dated 7/22/2022, after going on hospice services, states R1 is unable to care for own toileting needs. Interviews with residents R2, R3, R4, R5, and R6 indicated that their care needs are being met at the facility. ** Report continued on 9099-C ** Allegation: Facility staff physically restrain residents in care Interviews with staff members S1, S2, and Administrator indicated that they have never restrained a resident at the facility. Interviews with residents R2, R3, R4, R5, and R6 indicated that they never experienced being physically restrained at the facility. All interviews above indicated that they have never witnessed staff restrain a resident at the facility. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Allegation: Facility issued an unlawful eviction During the investigation, LPA obtained a copy of a 30-day eviction notice for resident (R1) from Administrator and relevant party. Both copies of eviction notice were identical. LPA obtained and reviewed correspondence from Senior Care Solutions sent to relevant party to relocate R1. 30-day eviction notice for R1 sent to relevant party authored by Administrator states the following: “I am giving you a 30 days notice to move [R1] to a place that is appropriate to your standards.” LPA observed that 30-day eviction notice issued to R1 was missing an effective date, resources available to assist in identifying alternative housing and care options, information about the resident’s right to file a complaint with community care licensing and State Ombudsman as well as contact information for both, and the following statement: "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Based on interviews conducted by the department 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 9099-D page. Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 8, 2023 · control 25-AS-20220805075858

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.683 · Plan of correction due date: Jun 23, 2023

§1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. In addition, the notice to quit shall include all of the following: (...) This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure to follow Health & Safety Code when issuing an eviction notice, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 8, 2023

Plan of correction: Facility will complete a statement of understanding regarding Health & Safety Code §1569.683. Facility will submit statement of understanding to LPA by POC due date of 6/23/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 9, 2023

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that R1 was following special diet, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 8, 2023

Plan of correction: Facility will complete a statement of understanding regarding regulation 87464. Facility will submit statement of understanding to LPA by POC due date of 6/9/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jun 9, 2023

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: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that R1 had transportation to all medical appointments, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 8, 2023

Plan of correction: Facility will complete a statement of understanding regarding regulation 87465. Facility will submit statement of understanding to LPA by POC due date of 6/9/2023.

Allegation investigated: Food supply is not adequate to meet the needs of the residents in care. Facility is too cold for residents in care.

On December 20, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived to deliver findings for complaint #25-AS-2021129140640. LPA met with Jae Yoel, Administrator and informed him the reason for 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 and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore a N-95 mask for Personal Protective Equipment.This agency has investigated the complaint alleging Food supply is not adequate to meet the needs of the residents in care and Facility is too cold for residents in care. LPA interviewed all residents (4) and staff (2) and reviewed documentation pertaining to the investigation. Interviews revealed that all clients get their needs met with no issues or concerns. LPA toured the facility and observed that the facility had the required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. The facility has two refrigerators, and both was full. To continue see 9099-C... Unsubstantiated The food pantry was checked and there is ample snacks, fruits and vegetables. Interviews have indicated residents have never been denied food at all. Allegation: Facility is too cold for residents in care. LPA's observed a comfortable temperature in the facility. LPA interviewed 4 residents and 2 staff. LPA conducted a total of 6 interviews. LPA learned that 4 out of 4 residents interviewed indicated the room temperature is fine. LPA learned from 2 staff interviews that the facility maintains a comfortable room temperature throughout the day with no issues. Based upon LPA's observations, interviews conducted with residents, staff and review of pertinent documents received, there is not substantial evidence to support or disprove that the alleged violations occurred. Due to the preponderance of evidence standard not being met by the department standard. There is no physical evidence to support the validity of the allegations as well as witness statements. LPA has deemed the complaint findings as UNSUBSTANTIATED. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted with Administrator Jae. A copy of this report was given.the state’s words, verbatim · CDSS document, Dec 20, 2022 · control 25-AS-20221129140640

Allegation investigated: Unqualified staff are dispensing medication Administrator is not at the facility for the required time

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Acting Administrator, Okki Kim, to deliver findings into the allegations listed above. LPA wore an N-95 mask. Facility staff wore masks while on the premises. During today’s visit, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Unqualified staff are dispensing medication ** Report continued on 9099-C ** Substantiated Interview with Administrator and Acting Administrator conducted on 4/21/2022 indicated that facility staff are administering injections to resident (R1) using "hand-over-hand" method. Administrator and Acting Administrator mimed method in which staff push down R1's thumb on injection to help administer medication. Interview with staff member (S1) conducted on 4/21/2022 indicated that S1 did not feel well trained enough to help with medication administration for R1, particularly injections. Interview with Acting Administrator conducted on 7/27/2022 indicated that facility stopped using "hand-over-hand" method when administering injections for R1 after LPA's visit on 4/21/2022. Facility now supervises R1 when self-administering injections. Allegation: Administrator is not at the facility for the required time Interview with Acting Administrator indicated that Administrator, Jae Yoel Kim, has not been at the facility since May 2022. Acting Administrator stated that they are at the facility twice a week for a time period that varies. Administrator and Acting Administrator were not at the facility at the time LPA arrived unannounced during inspections conducted on 4/21/2022 and 7/27/2022. Based on interviews conducted by the department 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 9099-D page. Exit interview was conducted with Acting Administrator. A copy of this report and appeal rights were provided. Acting Administrator's signature on these forms acknowledges receipt of these documents. During inspection conducted on 7/27/2022, LPA review resident files for residents R1, R2, R3, R4, R5, R6, and R7. During file review, LPA did not observe any prohibited health conditions with any of the residents receiving care, or previously receiving care, at the facility. During inspection conducted on 7/27/2022, LPA toured the facility and did not observe any residents with prohibited health conditions. Based on observation and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 27, 2022 · control 25-AS-20220413112225

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Jul 28, 2022

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: (5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. (…) This requirement is not met as evidenced by: Based on interviews conducted, the facility did not ensure that residents needing injections were self-administering medication, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 27, 2022

Plan of correction: Facility ceased "hand-over-hand" method of helping resident (R1) with injections after 4/21/2022 inspection. Facility will conduct a staff training on medication administration. Administrator will submit date of training and training material to LPA by POC due date of 7/28/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 11, 2022

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Based on interviews conducted and observation, the facility did not ensure that Administrator is at the facility for a sufficient amount of time, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 27, 2022

Plan of correction: Facility will assign Acting Administrator as Administrator. New Administrator will submit to LPA a weekly schedule indicating the times and days in which Administrator is working at the facility. Administrator will submit schedule to LPA by POC due date of 8/11/2022

Allegation investigated: Staff do not properly supervise residents

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Acting Administrator, Okki Kim, to open a complaint investigation into the allegation listed above. LPA wore an N-95 mask. Facility staff wore masks while on the premises. During today’s visit, LPA conducted interviews and requested documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Staff do not properly supervise residents ** Report continued on 9099-C ** Substantiated Interview conducted with Acting Administrator indicated that the facility has one (1) live-in staff member (S1) who sleeps at the facility at night but is on-call to assist residents with care throughout the night. LPA observed a time sheet for S1 indicating that S1 works 4 days a week from 8:00 AM to 4:30 PM. On days in which S1 is not working, staff member (S2) works from 7:00 AM to 7:00 PM. There is no time-sheets for Administrators. LPA reviewed resident records for residents R1, R2, R3, R4, R5, R6, and R7. Physician's Report (LIC 602) for R2 with a physician's signature dated 4/28/2022 indicates that R2 has a diagnosis of dementia. Preplacement Appraisal Information (LIC 603) for R2 dated 4/29/2017 indicates that R2 has "Alzheimer's dementia" and needs special observation/night supervision. Resident Appraisal (LIC 603A) for R2 dated 12/18/2018 indicates that R2 has "Alzheimer's Dementia" and needs special observation/night supervision due to confusion, forgetfulness, and wandering. Resident Appraisal (LIC 603A) for R2 dated 4/15/2022 indicates that R2 is "confused and disoriented, unable to communicate due to Dementia," and indicates both "yes" and "no" to R2 needing special observation/night supervision. 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 Acting Administrator. A copy of this report and appeal rights were provided. Acting Administrator's signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 27, 2022 · control 25-AS-20220726142625

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4)(A) · Plan of correction due date: Oct 14, 2022

87705 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 physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that R2, who has a dementia diagnosis, had awake night supervision, which poses an potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 27, 2022

Plan of correction: Facility will complete a statement of understanding regarding regulation 87415. Facility will submit statement of understanding to LPA by POC due date of 10/14/2022.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 4/21/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Jae Yoel Kim, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. LPA toured the facility to ensure the health and safety of the residents in care. Areas toured include but are not limited to: 6 bedrooms and 4 bathrooms for residents, common areas, dining room, food supply, garage, PPE supply, 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. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Apr 21, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Williams arrived at the facility unannounced on 06/3/2021 to conduct a Required 1- Year Inspection utilizing the infection control domain. LPA met with Caregiver, Julian Smith (Administrator was off today), 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 he 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 staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, Six (6) resident bedrooms, two (2) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and staff 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, Jun 3, 2021