Inland Christian Home

Allegation investigated: Staff are placing multiple diapers on the residents. Staff are not providing comfortable accommodations for the residents. Staff do not have planned activities for the residents. Staff mishandle the residents medications while in care. Inland Christian Home Staff do not provide adequate food services for the residents.

On 10/10/2023, at 10:09 AM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott conducted an unannounced visit to the facility to deliver findings for the above allegations. LPAs Brown and Wolcott identified themselves and discussed the purpose of the visit with Memory Care Director Denise Perez. The investigation was conducted by LPAs Brown and Wolcott. The investigation consisted of file review and interviews with relevant parties. The first allegation indicates Staff are placing multiple diapers on the residents. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with Staff # 1 (S1), Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) all indicated that they never placed multiple diapers on residents, and they all added that they never witnessed an incontinent resident at the facility wearing multiple diapers. Interviews with Resident #4 (R4) and Resident #5 (R5) revealed that they are wearing one (1) diaper. Moreover, residents and staffs’ interviews revealed that staffs’ are checking on residents to check on them if they needed to be change. *** Continuation on LIC9099C *** Unsubstantiated During the facility visit on 10/09/2023, LPAs Melody Brown and Bianca Wolcott observed residents wearing one (1) diaper. The second allegation indicates Staff are not providing comfortable accommodations for the residents. Interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) all indicated that they are providing comfortable accommodation for the residents. S2, S3 and S4 reported that they are asking residents on wheelchair every hour to transfer to a recliner chair to be comfortable if they are in the common area watching television (TV) and there is no incident that residents are just left in their wheelchair. S2, S3 and S4 added that there are residents that sometimes refused to be transferred to a chair and recliner, but they still continue asking them every hour. Resident #4 and Resident #5 interviews confirmed that staffs are transferring them to a chair or recliner chair to be comfortable when they are watching TV. During the visit on 10/09/2023, LPAs Brown and Wolcott observed staff transferred residents on wheelchair in a recliner chair for comfort. The third allegation indicates Staff do not have planned activities for the residents. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with Staff # 1 (S1), Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4), Staff #5 (S5) all indicated that they have planned activities for their residents everyday and there is no day that they do not have activities for their residents. Interviews with Resident #4 (R4) and Resident #5 (R5) revealed that the facility have activities for them everyday. During the facility visit on 10/09/2023, LPAs Brown and Wolcott observed residents attending the scheduled activity for the day at the Activity Room. The fourth allegation indicates Staff mishandle the residents medications while in care. Interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) all denied mishandling residents medications while in care. S1, S2, S3, and S4 all reported that they never pre-pour residents medications and there's no incident happened that a staff pre-poured a resident medication. Resident #4 (R4) and Resident #5 (R5) both confirmed that they are receiving their medications on time and there's no incident that staff mishandle their medications. The fifth allegation indicates Inland Christian Home Staff do not provide adequate food services for the residents. During the investigation, LPAs Brown and Wolcott did not find evidence to corroborate the allegation. ***Continuation in LIC9099C *** Interviews with Staff # 1 (S1), Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) indicated that the facility provide adequate food services for the residents. During the facility visit on 08/04/2023, LPA Brown obtained records of kitchen staffs updated food handlers card and ServSafe Certificate. In addition, LPA Brown observed the facility's Daily Dish Machine Sanitation Log for the month of August 2023. During the facility visit on 10/09/2023, LPAs Brown and Wolcott obtained the facility's Daily Dish Machine Sanitation Log for the month September 2023. Also, LPAs Brown and Wolcott observed the facility kitchen clean and sanitary during the visit on 10/09/2023. Based on interviews and records review, the allegations Staff are placing multiple diapers on the residents (Allegation #1), Staff are not providing comfortable accommodations for the residents (Allegation #2), Staff do not have planned activities for the residents (Allegation #3), Staff mishandle the residents medications while in care (Allegation #4), Inland Christian Home Staff do not provide adequate food services for the residents (Allegation #5) are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, where this report (LIC9099) was discussed and provided to Memory Care Director Denise Perez.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 56-AS-20230802093701

Type of visit: Case Management - Deficiencies

On 10/10/2023 at 10:09 AM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott met with Memory Care Director Denise Perez to initiate Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation. During the facility visit on 10/09/2023, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott reviewed documents and observed that Staff #6 (S6) does not have a current criminal background clearance and showing “in process” in Guardian system. Staff interview and records review indicated S6 had been working at the facility since 06/12/2023. In addition, LPAs Brown and Wolcott also notice Staff #7 (S7) working at the facility without a criminal background clearance since 09/18/2023. LPA Brown informed Memory Care Director Perez that deficiency will be issued as this pose immediate health, safety and personal rights risks to residents in care. Civil Penalty was assessed with the amount of $500.00 per individual during the Facility Visit for failure to obtain S6 and S7 Criminal Background Clearance. An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Memory Care Director Denise Perez.the state’s words, verbatim · CDSS document, Oct 10, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 11, 2023

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by: Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not obtaining criminal background clearance for Staff #6 and Staff #7 before allowing them to work at the facility which poses immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Licensee stated to train staff on CCR 87355(e)(1) and submit Training Log to LPA Brown by POC due date. Licensee stated to submit Signed Statement of Understanding on CCR 87355(e)(1) and submit to LPA Brown by POC due date.

Type of visit: Case Management - Deficiencies

On 08/04/2023 at 09:45 AM, Licensing Program Analyst (LPA) Melody Brown met with Memory Care Director Denise Perez to initiate Case Management Visit. The investigation consisted of observation, interviews and a review of pertinent documentation. During the facility visit on 08/04/2023 at 10:15 AM, LPA Brown reviewed documents and observed that Staff #4 (S4) and Staff#5 (S5) have a current criminal background clearance but S4 and S5 are not currently associated to the facility. Staff interviews and records review indicated S4 had been working at the facility since 06/07/2023 and S5 had been working at the facility since 02/19/2019. LPA Brown informed Memory Care Director Perez that deficiency will be issued as this pose potential health, safety and personal rights risks to residents in care. LPA Brown reviewed compliance history and observed that the facility was issued the same deficiency for a staff working at facility and the facility failed to transfer staffs’ criminal background clearance on 04/18/2023. Civil Penalty was assessed for repeat violation on Criminal Background Clearance within a 12-month period with the amount of $3,000.00 per individual and will continue to be assessed of $100.00 per day per citation until corrected during the facility visit today due to the facility allowed S4 and S5 to work and failed to transfer S4 and S5 Criminal Background Clearance to the facility. An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Memory Care Director Denise Perez.the state’s words, verbatim · CDSS document, Aug 4, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(2) · Plan of correction due date: Aug 14, 2023

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by: Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not transferring S4 and S5 criminal background clearance to the facility before allowing S4 and S5 to work at the facility which pose potential safety risks to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2023

Plan of correction: Licensee stated to transfer S4 and S5 criminal background clearance to the facility and associate S4 and S5 to the facility and submit proof to LPA Brown by POC due date. Licensee stated to submit proof of Staff In-Sevice Log on CCR 87355(e)(2) to LPA Brown by POC due date.

Allegation investigated: Staff do not ensure that residents are provided their medication(s) in a timely manner. Staff do not adequately supervise residents in care.

On 06/16/2023 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to continue the complaint investigation and deliver findings on the above allegations. LPA Brown was greeted and granted entrance by a staff at the reception area and Administrator Mary Wolff who was informed of the purpose of today’s visit. Memory Care director Denise Perez arrived during today's visit. The investigation consisted of staff interviews, observations of the memory care unit, and review of relevant records. The first allegation indicates Staff do not ensure that residents are provided their medication(s) in a timely manner. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs and residents indicated that staffs are providing residents medication(s) in a timely manner and no incident happened at the facility that a staff did not ensure that residents were not provided medication(s) in a timely manner. *** Continuation in LIC9099C *** Unsubstantiated Moreover, staffs interviews revealed that Licensed Vocational Nurses (LVNs) from Skilled Nursing and Assisted Living of the facility are assisting the residents in Memory Care to ensure that residents on insulin were provided their medication in a timely manner. LVNs reported to LPA Brown that no incident happened at the facility that a resident was not able to eat on time due to an incident that a resident was not able to received their medication on time. Also, during the facility visit last 04/18/2023 and 06/16/2023, LPA Brown observed certified nursing assistant (CNA) staffs/Medical Technicians administering medication to a resident during meals. In addition, LPA Brown reviewed Resident #1 (R1), Resident #2 (R2) Resident #3 (R3) and Resident #4 (R4) Medication Administration Records (MARs) and it indicated that their medications were administered in a timely manner. The second allegation indicates Staff do not adequately supervise residents in care. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Residents Interviews indicated that staffs are providing appropriate care and supervision to all the residents in care and that all staff are nice and helpful to all the residents. Interviews with staffs revealed that they are all providing adequate care and supervision to their residents at the facility and they are not allowed to use their phone while they are on duty. Moreover, staffs interviews indicated that all staffs are constantly monitoring all residents at the facility to make sure that their residents are adequately supervise and appropriately taken care of and no staff are distracted while on duty. Staffs and residents interviews also revealed that there's no incident happened at the facility that a staff did not adequately supervise a resident in care. Moreover, during the visit last 04/18/2023 and 06/16/2023, LPA Brown observed CNAs/staffs assisting residents in the Activity Room, in the hallway, in their room, in the common area/Day Program area during the tour of the facility with Memory Care Director Denise Perez. Based on the evidence, the allegation that Staff do not ensure that residents are provided their medication(s) in a timely manner (Allegation #1), Staff do not adequately supervise residents in care (Allegation #2) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Administrator Mary Wolff and Memory Care Director Denise Perez.the state’s words, verbatim · CDSS document, Jun 16, 2023 · control 56-AS-20230412170744

Allegation investigated: Resident sustained a pressure injury while in care Residents toileting needs are not met Staff mismanaged residents medication Staff are not adequately trained Staff failed to properly supervise residents resulting in residents falling

Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent unannounced visit to the facility to continue the complaint investigation and deliver findings on the above allegations. LPA met with administrator Mary Wolff who was informed of the purpose of today’s visit. Memory Care director Denise Perez arrived during today's visit. The investigation consisted of staff interviews, observations of the memory care unit, and review of relevant records. Allegation 1: Resident (R1) sustained a pressure injury while in care. LPA was not able to interview Resident 1 (R1). Records received revealed that R1 began receiving hospice services in the middle of February 2022 and was being seen by a shower aid twice a week and a registered nurse twice a week. Staff interviews also revealed that R1 developed stage 1 pressure sores that healed without medical intervention. Allegation 2: Residents’ toileting needs are not met. Staff interviews revealed that residents are encouraged to toilet every two hours and residents who wear briefs are changed every two hours or sooner as needed. Unsubstantiated Interviews with residents revealed that toileting needs are met. During staff interviews, it was discovered that the facility unit does not keep toileting log as all residents require some toileting assistance. Allegations 3: Staff mismanaged residents’ medication; and Allegation 4: Staff are not adequately trained. LPA observed that the medication room is locked and secured. LPA confirmed that unit staff present during today’s visit hold active certified nursing assistant (CNA) and licensed vocational nursing (LVN) licenses. Staff interviews confirm that medication training includes watching medication management and administration videos and at least 40 hours of hands-on shadowing with a tenured medication technician. LPA observed staff administering medication to a resident during meals. Allegation 5: Staff failed to properly supervise residents resulting in residents falling. LPA reviewed special incident records and found that R1 had three reported falls in 2019. LPA found that the facility reported three resident falls and two hospitalization not related to Covid-19 between 2021 through 2023. LPA observed multiple residents ambulating, independently and with walking assistive devices, and residents who use wheelchairs. Based on the information from today's investigation, these five allegations are therefore 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 evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Denise Perez, Memory Care Director.the state’s words, verbatim · CDSS document, Apr 28, 2023 · control 18-AS-20220228123141

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent unannounced visit to this facility to continue the investigation and deliver findings of complaint number 18-AS-20220228123141. During the investigation, LPA discovered that the facility has not submitted any incident report to Community Care Licensing (CCL). LPA further found that there were two resident deaths that were not reported to CCL. This poses a potential health, safety, and personal rights risk to residents in care. Refer to LIC809-D for deficiency issued. An exit interview was conducted with and a copy of this report, LIC809-D, and appeal rights were provided to Memory Care Director Denise Perez.the state’s words, verbatim · CDSS document, Apr 28, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: May 5, 2023

(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... (A) Death of any resident from any cause regardless of where the death occurred... This requirement was not met as evidenced by: LPA reviewed special incident reports and found that the facility has not reported any incidents in 2023, specifiaclly two residents deaths in 2023.the state’s words, verbatim · CDSS document, Apr 28, 2023

Plan of correction: Facility shall submit death report for two unit resident deaths that occurred in 2023. Facility shall review RCFE reporting guidelines as indicated in CCR 77211.

Type of visit: Case Management - Deficiencies

On 04/18/2023 at 12:03 PM, Licensing Program Analyst (LPA) Melody Brown met with Memory Care Director Denise Perez to initiate Case Management Visit. The investigation consisted of observation, interviews and a review of pertinent documentation. During the facility visit last 04/18/2023 at 12:03 PM, LPA Brown reviewed documents and observed that Staff #3 (S3) have a current criminal background clearance but S3 is not currently associated to the facility. Staff interviews and records review indicated S3 had been working at the facility for five (5) years now. LPA Brown informed Memory Care Director Perez that deficiency will be issued as this pose potential health, safety and personal rights risks to residents in care. Civil Penalty was assessed with the amount of $500.00 during the Facility Visit for failure to transfer S3 Criminal Background Clearance to the facility. In addition, interviews with staffs and residents indicated that Certified Nursing Assistants (CNA)/Medical Technicians (MedTech) are performing residents' blood glucose testing. Memory Care Director Perez confirmed to LPA Brown that the CNAs and MedTechs at the facility are performing residents' blood glucose testing during the facility visit 04/18/2023. LPA Brown explained to Memory Care Director Perez that blood glucose testing must be administered by an appropriately skilled professional and CNAs and MedTechs must stop from performing blood glucose testing to residents today, 04/18/2023 and Memory Care Director Perez expressed understanding. LPA Brown indicated that deficiency will be issued as this pose immediate health, safety and personal rights risks to residents in care, An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Memory Care Director Denise Perez.the state’s words, verbatim · CDSS document, Apr 18, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Apr 19, 2023

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by allowing CNAs/MedTechs to perform blood glucose testing to residents which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2023

Plan of correction: Licensee stated to not allow CNAs/MedTechs staff to perform blood glucose testing today 04/18/2023 and will submit proof of appropriately skilled professional performing blood glucose check to LPA Brown by POC due date. Licensee will submit signed Statement of Uunderstanding on CCR 87628(a) to LPA brown by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87355(e)(2) · Plan of correction due date: Apr 25, 2023

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (2)Request a transfer of a criminal record clearance... This requirement is not met as evidenced by: Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not trasferring S3's crimminal backround clearance to the facility before allowing S3 to work at the facility which pose potential safety risks to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2023

Plan of correction: Licensee stated to transfer S3's criminal backround clearance to the facility and associate S3 to the facility and submit proof to LPA Brown by POC due date. Licensee stated to submit signed Statement of Understanding on CCR 87355(e)(2) to LPA Brown by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bernadette Allen and Rohit Lama conducted an unannounced visit to the facility for an annual inspection. LPA met with Administrator Mary Woff. LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients. LPA toured independent Living, Memory Care, and Assisted Living facility inside and out. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. The outdoor and indoor hallways were free of obstruction. Cleaning supplies and medications were kept in a safe and locked place. The facility had a complete first aid kit and emergency supplies for LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review. The client rooms had the required furniture and sufficient lighting. There were handrails in all bathrooms to accommodate the needs for bathing and showers have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water temperature in the client bathrooms. The hot water temperature measured at 105.4 degrees F. LPA observed hand sanitizer throughout the facility and a 30- day supply of PPE. All clients have at least a 30 -day supply of medications. LPA observed that all emergency contact information for the clients have been updated. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.the state’s words, verbatim · CDSS document, Feb 22, 2022