Alta Loma Gardens Residential Care #1

Type of visit: Office

Licensing Program Analyst (LPA) Bernadette Allen met with Ana Pleitez Stark Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 11/08/2023 at 10:50 AM to initiate a Case Management Office Visit. LPA Allen requested that Ana Pleitez Stark come to the office to sign an amended complaint investigation control number 18-AS-20210430090536 that was conducted on 10/28/2023. The report was missing an allegation and investigation information. An exit interview was conducted where this report was discussed, and a copy was provided to Ana Pleitez Stark at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 8, 2023

Allegation investigated: Staff are mismanaging medications. Staff do not have appropriate training.

Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to deliver the findings for the allegations listed above. LPA met with Administrator Ana Pleitez Stark who left during the visit and gave her care staff Lavonne Brinley approval to sign report. The investigation consisted of interviews with two (2) staff members who stated that they have not been documenting the MAR for the clients in care.The administrator has also confirmed that accurate documentation has not been conducted per CCL requirements. The interviews also revealed that the licensee has not been conducting any quarterly or annual training for the staff and proof of training could not be provided at the time of the visit. Based on the evidence gathered during the investigation, the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited on the attached LIC 9099-D. Substantiatedthe state’s words, verbatim · CDSS document, Oct 28, 2023 · control 18-AS-20210430090536

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(2)(B) · Plan of correction due date: Nov 4, 2023

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual... (2) This training shall be...(B) Importance and techniques of personal care... This requirement is not met as evidenced by: Based on observations, interviews and record review, the Licensee did not comply with section cited above by having S2 and S3 worked at the facility without the required initial/annual training which poses immediate health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 28, 2023

Plan of correction: Licensee has agrred to submit Proof of Required Trainings of all staff to LPA Allen by POC due date. Licensee has agreed to submit a Signed Statement of Understanding on CCR 87411(c)(2)(B) by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Nov 4, 2023

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications...(6) The licensee shall be responsible for assuring that a record... This requirement is not met as evidenced by:Based on observations, interviews and record review, the Licensee did not comply with section cited above by not document in R1-R5 Medication Administration Record (MAR) the administration of any residents’ medications at the time they were given all pages were blank. This poses a potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 28, 2023

Plan of correction: The licensee has agreed to train all staff on CCR 87465(h)(6) and submit Training Log to LPA Allen by POC due date. Licensee also agrees to submit a signed Statement of Understanding on CCR87465(h)(6) to LPAllen by POC due date.

Allegation investigated: Residents sustained pressure injuries while in care. Staff are not assisting residents with ADLs. Administrator is not fulfilling management duties. Facility does not have sufficient staffing.

Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to deliver the findings for the allegations listed above. LPA met with Lavonne Brinley Support Staff who left during the visit and gave her care staff Lavonne Brinley. The investigation consisted of interviews with the administrator, two (2) staff members, four (4) residents and review of five (5) residents files. LPA interviewed two staff members who stated there was only one resident at the facility in the past who was diagnosed with a pressure injury but was being treated by hospice three times a week. LPA also observed documentation that confirms there was one resident with a pressure injury and was being treated by hospice. The interviews with the staff were asked if staffing was sufficient, and they stated they would like to have additional staff at night, but they manage with who they have. LPA also reviewed staff schedule that reflect there is sufficient staff for night shift. The interviews with the four (4) residents stated that their (ADL’s) activities of daily living were being met daily by staff members. The interviews with staff and administrator all stated the administrator is at the facility daily. During the visit LPA observed that there was sufficient staff, residents ADL’s appeared to be met and the administrator was at the facility upon arrival. Based on interviews, documentation, and observations the allegations are Unsubstantiated. A finding of unsubstantiated means although the allegations 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 with appeal rights to Lavonne Brinley Support Staff at the conclusion of the visit. Unsubstantiated LPA was unable to interview resident 1(R1) because they are deceased. LPA observed the facility files for Resident 1(R1) and their file did confirm that they were being treated by a hospice Agency off and on from 2019 through 2023. Based on the interviews and file review the above finding is Unsubstantiated. A finding of unsubstantiated means although the allegations 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 Lavonne Brinley at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Oct 28, 2023 · control 18-AS-20210430090536

Allegation investigated: Staff failed to destroy previous residents’ centrally stored prescription medications. Staff left resident in soiled clothing for extended amount of time

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate and deliver findings on the above allegations. LPA met with administratopr, Ana Stark who was informed of the purpose of the visit. LPA conducted interviews, documented observations, and conducted records reviews. Regarding “Staff failed to destroy previous residents’ centrally stored prescription medications.” LPA reviewed where the facility stores the centrally stored medications. During the facility tour it was found that prior resident, R1’s medication was being kept in the facility garage. It was found through interview that the resident had moved out one (1) year prior. (continued on 9099-C page) Substantiated The administrator stated they had forgotten to destroy the medication. LPA requested destruction records for previous residents and found that that R2 had a documented destruction record for medications. During the time of the visit, the administrator destroyed R1’s medication and documented this. Due to medication being found during the time of today’s visit that the administrator failed to destroy, the allegation is substantiated. Regarding “Staff left resident in soiled clothing for extended amount of time.”, it was alleged that overnight staff at the facility were not changing resident and as a result were left soiled overnight. LPA interviewed night staff at the time of the visit who stated that residents were changed every 2 hours, including overnight. They stated R3 was the only incontinent resident at this time of the interview, June 23, 2023. LPA reviewed the incontinence accountability log for R3 and found that on several occasions the resident was not documented as changed after 5pm, with next time changed as 5am. Therefore the allegation is substantiated. A finding of substantiated means the preponderance of the evidence standard has been met. Substantiated finding was cited under Title 22 Division 6 Chapter 8. Plan of correction was made with the administrator. An exit interview was conducted with administrator, Ana Stark where this report, LIC9099-D and appeal rights were reviewed and provided to them. LPA interviewed the administrator and (1) staff present during today’s visit, who stated that a protein is served to the resident every day. LPA observed during the visit that resident were fed protein for lunch. Therefore, the allegation is unsubstantiated. Regarding “Staff used resident's personal care products on other residents”, it was alleged that staff used private pay residents supplies when the facility ran out. LPA interviewed staff and administrator during the time of the visit who stated that all current residents provide their own supplies. The administrator stated they have a subscription service with Amazon since the facility opened, and receive incontinent supplies on a monthly basis. LPA observed the facility’s incontinent supplies and found that there were enough supplies to be used in case resident ran out of their supplies. LPA also observed (3) resident rooms for incontinent supplies and found that had extra supplies in their room, including supplies that the administrator had supplied them. Therefore the allegation is unsubstantiated. Regarding “Staff failed to protect resident from sustaining injury.” It was alleged that R4 had gone to the liquor store and bought liquor, had become intoxicated at the facility, which resulted in a fall and stitched to R4 forehead. LPA interviewed administrator who stated that the resident only went on supervised outings to the store, with them and staff 1 (S1). They stated that R4 did not purchase alcohol during their time at the facility. R4 is unable to be interviewed as they are now deceased. LPA interviewed S1 during the time of the visit who stated that R2 did sustain a fall where the resident had to have stitched to their forehead, but that this fall had occurred at night when the resident got up to go to the bathroom. LPA could not find any evidence to corroborate the allegation. Therefore, the allegation is also unsubstantiated. A finding of unsubstantiated means that although the allegation is valid, the preponderance of the evidence standard has not been met. An exit interview was conducted where this report was reviewed and provided to Administrator, Ana Stark.the state’s words, verbatim · CDSS document, Jun 23, 2023 · control 18-AS-20200819151426

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87456(i) · Plan of correction due date: Jun 24, 2023

(i) Prescription medications...which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years...This requirment was not met as evidenced by: R1's medication which had not been disposed of and kept in the facility garage during the time of the visit.the state’s words, verbatim · CDSS document, Jun 23, 2023

Plan of correction: The administrator disposed of the medication immediately during the visit. The administrator agreed to send a certified statement on new prcodure for destructing medication.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Jun 27, 2023

(b) In addition... the licensee shall be responsible for the following:(2) Ensuring that incontinent residents are checked...including during the night.This requirment was not met as evidenced by: Based on records review and intervie wit was round that R3 was not being changed after 5pm, and changed again until 5am. This is a potential health, saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 23, 2023

Plan of correction: The licensee agreed to retrain staff on incontinent care by the POC due date.

Type of visit: Case Management - Deficiencies

On this day Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to amend a case management deficiency report issued on 05/04/2023. The deficiency was issued in relation to complaint number: 18-AS-20211223163003. LPA met with care staff Fidel Tabi and AJ Espino who phoned licensee Margarita Stark. Stark arrived shortly and was informed of the purpose of today's visit. This facility is licensed to admit residents with Dementia and the facility submitted a Dementia care plan with its plan of operation at the time of licensure. The deficiency CCR 87208(c) issued on 05/04/23 is therefore invalid. The deficiency for incomplete records CCR 87506(b) is still in place. During today's visit, LPA reviewed records and received proof of correction for all residents. A Letter of Deficiency Citations Cleared was issued during today's visit. An exit interview was conducted where this report was discussed with and provided to Licensee.the state’s words, verbatim · CDSS document, May 15, 2023

Allegation investigated: Resident developed pressure injuries while in care.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on the above allegation. LPA met with administrator Margarita Stark and informed her of the purpose of this visit. The investigation included interviews with relevant parties, records reviews, and observations of the physical plant. LPA was not able to interview Resident 1 (R1). LPA was provided with an incomplete LIC 602, physician’s report, as it was missing pages 3 and 4 that included allergies, other conditions, physical health status, mental condition, capacity for self-care, and medication management. LPA received home health records from 10/1/2021 through 3/7/2022. The allegation is R1 developed pressure injuries while in care. Interviews with relevant parties could not specify when R1 first moved into this facility however, Administrator stated that R1 moved in as early as January 2021 and moved out by 11/30/2021. Review of the LIC 602 state that R1 suffers from chronic venous ulcers and wound care is provided by a home health agency three times a week. Interviews with former caregivers and Unsubstantiated wound nurse confirm that R1 is able to walk with an assistive device however R1 preferred to stay and sleep on their recliner. Home health recertification (11/8/21 visit) conducted by a registered nurse (RN) notes state that R1's skin was pink and dry with Stage 2 pressure ulcers on both buttocks, and present with stasis ulcers. Additionally, former wound nurse and caregiver interviews confirm that R1’s wound areas were consistently washed and dried by facility staff and cleansed by the nurse. Wound nurse continued to see R1 till 11/26/21 noting that the buttocks ulcers had no drainage or symptoms and/or signs of infection. Home health visit on 11/29/21 was completed by RN noted that the buttocks ulcers were in the similar condition from 11/26/21. RN visited R1 at a new facility in another county. On 12/1/21 RN stated that the buttocks ulcers had no drainage or symptoms and/or signs of infection. RN visited R1 on 12/3/21 and noted same instruction about R1 staying in a recliner. Additional 12/3/21 notes state no open ulcers, buttock's ulcers are pink, no drainage and no signed and symptoms of infection. Based on the above information, the allegation is 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 Margarita Stark.the state’s words, verbatim · CDSS document, May 4, 2023 · control 18-AS-20211223163003

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to deliver findings to complaint number 18-AS-20211223163003. LPA met with Margarita Stark who was informed of today's visit. During the investigation of the above mentioned complaint number, it was discovered that the facility did not have full records for R1 and that R1 was diagnosed with Dementia. This facility is not licensed to admit Dementia residents and this facility does not hold a dementia care plan. These pose an immediate health and safety risk to residents in care. Refer to LIC-809D for deficiency cited. An exit interview was conducted with and a copy of this report, LIC809-D, and appeal rights were provided tothe state’s words, verbatim · CDSS document, May 4, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(c) · Plan of correction due date: May 12, 2023

Plan of Operation - A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement was not met as evidenced by: Resident 1 has a diagnosis of Dementia. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2023

Plan of correction: Licensee shall submit to the Department a memorandum of understanding of sections 87208(c) and 87705 no later than then end of POC date. Resident 1 has not lived at this facility since December 2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b) · Plan of correction due date: May 12, 2023

Resident Records - Each resident’s record shall contain at least the following information... This requirement was not met as evidenced by: Records received by LPA for Resident 1 are missing admissions agreement, hospice notes, incomplete functional assessment, and appraisal. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2023

Plan of correction: Licensee shall evaluate all resident records for accuracy and submit to the Department a memorandum of understanding of section 87506 no later than then end of POC date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Anna Bueno arrived at the facility for the purpose of following up on open complaint #18-AS-20211223163003 requested records. LPA met with care staff Raymond Munsayac who was informed of the reason for today's visit. Munsayac phoned Licensee Ana Stark who was not present in the facility. Stark informed LPA that they will not be able to provide records to LPA during today's visit as the records were not accessible at this time. On 12/28/2021, LPA Anna Bueno conducted the initial complaint visit to this facility and requested records. On 12/29/2021, LPA Bueno sent electronic message to Licensee requesting for records and Licensee responded to LPA that they will work on the request on this day. On 1/13/2022, LPA Bueno sent an electronic message to Licensee following up on the requested records and Licensee sent a response stating that they will work on this today. On 2/14/2023, LPA Bueno phoned the Licensee about the open complaint and sent an electronic request for Licensee to forward any submitted to any other LPAs between 1/14/22 through today's notification. During today's call with Licensee, Licensee was unable to verify if records were sent to another LPA at any time. LPA Bueno was not able to review and/or receive any records related to this complaint on this visit or at any other time LPA Bueno requested for records. LPA observed Staff 1 (S1) has a criminal background clearance but was not associated to this facility. These pose an immediate health and safety risk to residents in care. Refer to LIC809-D for deficiencies cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Raymond Munsayac.the state’s words, verbatim · CDSS document, Feb 22, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87755(c) · Plan of correction due date: Feb 23, 2023

Inspection Authority of the Licensing Agency: (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement was not met as evidenced by: LPA was not able to review any records requested for complaint# 18-AS-20211223163003.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: Licensee shall submit all requested records in person or electronically to LPA Bueno and/or the San Bernardino Regional office no later than close of business POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Feb 22, 2023

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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement was not met as evidenced by: LPA Bueno confirmed that S1 has a person number but is not associated to this facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 22, 2023

Plan of correction: Licensee shall associate S1 to this facility no later than close of business POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection with an emphasis on infection control. LPA identified herself to care staff Alvin Espino. Staff verified that the facility currently has no active and/or suspected COVID-19 cases. Staff notified administrator by phone of today's visit. During the inspection, LPA Bueno interviewed care staff regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings in the facility, including COVID-19 symptoms and infection control postings, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and that staff are trained in the facility's infection control measures. The facility has yet to submit their COVID-19 mitigation plan. During the inspection, LPA did not observe tags on two of two fire extinguishers and staff is unable to verify when extinguishers were last tested. LPA observed sprinkler systems installed in the home. LPA observed that staff 1 is not associated to the facility, which poses an immediate health and safety risk to persons in care. Refer to LIC809D for deficiencies cited. Technical advisories were also issued. See LIC9102s for advisories. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Alvin Espino at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Jun 20, 2022

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility for the purpose of conducting a health and safety visit in relation to complaint number 18-AS-20211223163003. During the visit LPA toured the facility with Staff inside and out. Residents in care and visitors were present during today's visit. LPA observed that residents appeared to be safe with no imminent health/safety concerns observed. No health/safety hazards were observed. LPA inspected the outside perimeter of the facility and observed no health/safety hazards. There was a sufficient amount of staff present at the facility to provide care for clients. LPA inspected facility food supplies and observed an adequate supply of perishable and non-perishable food. The needs of the residents in care appear to be met during this inspection. Administrator Stark left the facility before the conclusion of the visit but was advised that the exit interview was conducted and a copy of this report was discussed with Staff.the state’s words, verbatim · CDSS document, Dec 28, 2021

Allegation investigated: Staff failing to meet residents care needs

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of following up on an open complaint with the above allegation(s). LPA Colvin met with Licensee/Administrator "Margarita" Ana Stark and advised them of the purpose of today's visit. Below is a summary of the findings of the complaint. Regarding allegation "Staff failing to meet residents care needs": LPA Colvin conducted interviews with current residents at the facility, as well as family members and responsible parties of residents who lived at the facility during the time of the complaint, but are no longer present. LPA Colvin's interviews did not result in any concerns regarding staff not meeting residents' needs. Additionally, LPA Colvin did not observe any visible concerns with the residents during today's inspection. Therefore, due to interviews and observations, the allegation "Staff failing to meet residents care needs" is UNSUBSTANTIATED. finding of 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. An exit interview was conducted with Licensee/Administrator "Margarita" Ana Stark and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 21, 2021 · control 18-AS-20200325093433

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff failed to notify resident’s authorized representative prior to resident signing document(s)

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of delviering findings for the complaint with the above allegation(s). LPA Colvin met with Licensee "Margarita" Ana Stark and advised them of the purpose of the visit. Below is a summary of the findings of the complaint. Regarding allegation "Staff failed to notify resident’s authorized representative prior to resident signing document(s)": LPA Colvin conducted interviews and reviewed resident's (R1) facility file and Power of Attorney (POA) documents. Through interviews conducted, LPA Colvin confirmed that R1 signed paperwork for services for an outside person/agency, and that Licensee/Administrator had some knowledge of this agreement. However, through careful review of R1's most recent Physician's Report and POA document, LPA Colvin observed that R1 has what is known as a "Springing POA", which only becomes effective when R1 becomes incapacitated. In order for R1 to be declared incapacitated, R1 would need to be evaluated by a physician, who then makes a declaration on whether or not R1 is incapacitated. LPA Colvin did not observe any documentation in R1's file showing that this determination had been made. Unfounded Additionally, R1's POA has additionally acknowledged that R1 has not been evaluated or determined to be incapacitated, and therefore, the POA is not yet active. Therefore, based on interviews and record review, the allegation of "Staff failed to notify resident’s authorized representative prior to resident signing document(s)" is UNFOUNDED. This agency has investigated the complaint alleging "Staff failed to notify resident’s authorized representative prior to resident signing document(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. An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator "Margarita" Ana Stark.the state’s words, verbatim · CDSS document, Dec 21, 2021 · control 18-AS-20201201115558

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of following up on an open complaint investigation (#18-AS-20200325093433) and conducting additional interviews. During LPA Colvin's inspection today, LPA Colvin observed the following violations of Title 22 Regulations and Health and Safety Code: Unassociated Staff - LPA Colvin observed that 1 of 2 staff (S1) present at the facility during today's inspection was not associated to the facility. LPA Colvin confirmed that S1 did have fingerprint clearance, but has been working part time at the facility for three months and has not had their fingerprint clearance transferred to this facility. Deficiency cited. LPA Colvin previously cited this facility for the same violation on 5/4/21. Since this is the facility's second violation within a 12 month period, civil penalties are being assessed in the amount of $100 per day, with a maximum of 30 days instead of 5. LPA Colvin will be citing for the maximum of 30 days, as S1 has been working at the facility for 3 months. $100 a day x 30 days = $3,000 in civil penalties being assessed. Construction to Building - During LPA Colvin's tour of the facility, LPA Colvin observed that the back master bedroom (cleared for bedridden residents), has had two walls and a sliding glass door installed halfway through the room, sectioning off another make-shift room, which LPA Colvin observed to be fully furnished with a bed. LPA Colvin observed that this construction was not present during her last inspection at the facility on 5/4/21, and additionally, LPA Colvin did not observe any notes in LPA Colvin's system showing that the Licensee had contacted Community Care Licensing (CCL) about the construction, nor that a new floor plan had been submitted. Additionally, this change would require approval from the Fire Marshall, as the structure may affect the facility's fire clearance. Deficiency cited. Licensing Fees - LPA Colvin observed that the Licensee has not paid their annual fees for the year. These fees were due on the anniversary of the license, in February. The Licensee has additionally accrued a late charge due to the fees being overdue. As of 12/21/21, the Licensee owes $742. Deficiency cited. Unsafe Walkway/Pavement - Upon LPA Colvin's arrival to the facility, LPA Colvin observed that there was a large section of pavement in the driveway, approximately 4 - 5 feet in length, which was broken and cracked, with some areas uneven, causing the ground to abruptly change height. LPA Colvin used a writing pen to measure the difference in the height of the pieces of pavement, and estimates the difference to be at least 2 inches. This is a potential hazard to the residents, staff, and visitors, as someone could trip and fall while walking up to the facility. LPA Colvin notes that the property/parcel of land has multiple properties on it, but the driveway is included in the facility's sketch, and therefore is included in the license and is considered part of the facility and the responsibility of the Licensee. Deficiency cited. An exit interview was conducted and a copy of this report, LIC809D, civil penalty forms and appeal rights, along with LIC 811 was provided to to Licensee/Administrator "Margarita" Ana Stark.the state’s words, verbatim · CDSS document, Dec 21, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 22, 2021

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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met by: Based on record review and observation, the Licensee did not comply with the above requirement with one staff. LPA Colvin observed that S1 did not have their criminal record clearanced transferred to the facility. This is an immediate safety risk for all residents.the state’s words, verbatim · CDSS document, Dec 21, 2021

Plan of correction: Licensee agrees to either submit the paperwork required to the Riverside Regional Office to have S1's criminal record clearance trasnferred to the facility, or for the Licensee to mannual complete the transfer via Guardian website. Licensee to provide LPA Colvin with proof of transfer by the Plan of Correction date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87305(a) · Plan of correction due date: Jan 11, 2022

Alterations to Existing Building or New Facilitie: (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by" Based on observations and record review, the Licensee did not comply with the above regulation with one room of the facility. LPA Colvin observed the master bedroom to have two new walls installed to seperate the room. CCL was not notified of the construction. This is a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 21, 2021

Plan of correction: Licensee agrees to submit proof of a building permit to CCL and to consult with the Fire Marshall and County Code Enforcement regarding the safety and permission from both agencies for the construction. Licensee to provide written approval of construction from both agencies to LPA Colvin by the Plan of Correction date of 1/11/22.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.185(e) · Plan of correction due date: Jan 11, 2022

Fees for license or applications; use of revenues; collected; denial or forfeiture: (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with the facility's licensing fees. LPA Colvin observed that the Licensee owes $742. This is a potential safety risk for all residents, as the license may be revoked.the state’s words, verbatim · CDSS document, Dec 21, 2021

Plan of correction: Licensee agrees to pay all fees due by Plan of Correction date of 12/13/21. Licensee may self-certify to LPA Colvin once payment has been made.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jan 11, 2022

Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met by: Based on observatons, the Licensee did not comply with the above regulation with one area of the facility. LPA Colvin observed a 4-5 foot area of concrete in the driveway which was cracked and uneven, with height differences of approximately 2 inches. This is a potential safety risk to residents & visitorsthe state’s words, verbatim · CDSS document, Dec 21, 2021

Plan of correction: Licensee agrees to have the conrete in the driveway repaired so that it does not present a potential fall risk to persons entering or exiting the facility. Licensee to provide LPA Colvin with photographic proof of the repaired driveway by the Plan of Correction date of 1/11/22.