Hesperia Senior Care

Type of visit: Case Management - Other

On 02/1/2023, at 10:18 a.m., Licensing Program Analysts (LPA) Rayshaun Nickolas made an unannounced visit to the facility to obtain signatures on amended LIC 9099s. LPA met with Licensee/Administrator Jin A. Wang and explained the purpose of the visit. An exit interview was conducted and a copy of this report and amended LIC 9099s were provided to Wang.the state’s words, verbatim · CDSS document, Feb 1, 2023

Allegation investigated: Unqualified staff dispensing medication

Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to deliver the finding on the above allegation. LPA met with Raeanne Rios and explained the purpose of the visit. Rios called the Licensee, and the Licensee was unavailable to attend. LPA obtained permission from the Licensee to discuss this report with Rios and for Rios to sign the report on their behalf. The investigation consisted of file reviews and interviews with relevant parties. The allegation alleges that on April 5, 2022, or April 6, 2022, a member of the facility's staff was overheard reprimanding, screaming, and crying about the staff working at the facility not qualified to dispense medication. An interview with the Licensee revealed that only the certified nursing assistants (CNAs) working at the facility could dispense medication, not caregivers. The Licensee stated that care and compliance Compact disc (CD) training was provided to staff and provided proof of the staff’s training record. However, page nine (9) of the facility’s program description on medication training states, “any staff member assisting residents with the self-administration of medication are required to complete six (6) hands-on shadowing hours before working independently with a resident. Substantiated An additional four (4) hours of initial medication training must also be completed within the first two (2) weeks of medication staff employment”. Page nine (9) of the facility’s program description on medication training further states, “after completing ten (10) hours of training, the employees will be tested on their comprehension and competency in medication assistance. The test result will be filed in the employee’s personnel file. In each succeeding twelve (12) month period, an additional eight (8) hours of training will be conducted with the employee on medication-related issues”. The Licensee failed to provide sufficient evidence that staff dispensing medication were qualified as outlined in the facility’s program description. Based on the evidence gathered during the investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were discussed and provide. Allegation #2 “Staff are not adequately trained”. The allegation alleges that on April 5, 2022 or April 6, 2022, the RP does not believe that the facility staff received proper training based on the reprimand they overheard from a staff member that quit. LPA interview with Licensee revealed that staff was provided compact disc (CD) training from a company called Care and Compliance group. The Licensee also provided documentation of facility staff training. LPA interview with facility staff #2 (S2) revealed that Digital Versatile Disk (DVD) training videos were provided. The investigation into this incident revealed insufficient evidence to corroborate the allegation. Allegation # 3 “Staff did not notice a change in resident's condition”. The allegation alleges that on April 5, 2022 or April 6, 2022, C1 was observed by the RP lying on the floor. RP states that C1 was lying on the floor in their room and bleeding badly at the top of their head. The RP further stated that C1 lay on the floor for some time, and staff did not check on them or notice any changes in their condition. LPA interview with the Licensee revealed that C1 did not suffer any injury on any of the alleged dates. LPA interview with staff #1 (S1) revealed that C1 did fall, but S1 did not remember the exact date. However, S1 did provide a time frame, using weeks, and that time frame excluded April 5, 2022, or April 6, 2022. S1 also stated that 911 and the house manager were called when C1 fell. The investigation into this incident revealed insufficient evidence to corroborate the allegation. Allegation #4 “Staff yelling at resident”. The allegation alleges that on April 5, 2022 or April 6, 2022, The RP overheard staff yelling at a resident. LPA interview with the Licensee revealed that no client or another member of the Licensee’s staff has ever reported to the Licensee that staff is yelling at a resident. LPA interview with S2 revealed that they had not received complaints from staff or clients about staff yelling at a resident. The investigation into this incident revealed insufficient evidence to corroborate the allegation. Based on the investigation, the above findings 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.the state’s words, verbatim · CDSS document, Jan 13, 2023 · control 56-AS-20220509085953

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a)(6) · Plan of correction due date: Jan 27, 2023

87208 Plan of Operation (a)(6) (6) Plan for training staff, as required by Section 87411(c). This requirement was not met as evidenced by: Based on file review & interview, the Licensee did not ensure that staff training and proof of staff training were followed as outlined in the facility's program description on medication training.the state’s words, verbatim · CDSS document, Jan 13, 2023

Plan of correction: The Licensee shall read section 87208(a)(6) and 87411(c) of the California Code of Regulation (CCR). Licensee shall submit a letter of understanding to the Regional Office (RO) by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Rayshaun Nickolas and Bernadette Allen conducted a case management visit in response to deficiencies cited at the facility. LPAs met with caregiver Reanne Rios and explained the purpose of the visit. Rios called the administrator, per the LPAs request. During the visit, LPAs toured the facility and requested to review the resident's records. Rios could not provide the residents' medical records as asked because records were locked, and Rios stated not have access to the office key. Based on observations and interviews made during today’s inspection, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR). An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, May 12, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: May 16, 2022

87755 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... This requirement was not met as evidence The facility's staff could not provide the residents' records as requested by LPA. The facility staff did not have the key to access the records.the state’s words, verbatim · CDSS document, May 12, 2022

Plan of correction: Licensee shall provide access to residents' records to all staff. Proof of correction shall be submitted to LPA on the POC due date of May 16, 2022 by the close of business.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(e)(2) · Plan of correction due date: May 16, 2022

87755 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... This requirement was not met as evidence The facility's staff could not provide the residents' records as requested by LPA. The facility staff did not have the key to access the records.the state’s words, verbatim · CDSS document, May 12, 2022

Plan of correction: Licensee shall provide access to residents' records to all staff. Proof of correction shall be submitted to LPA on the POC due date of May 16, 2022 by the close of business.

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegation. LPA Williams identified herself to Administrator, Jin Wang, who was also informed of the purpose of the visit. The investigation consisted of records review and interviews with residents and staff. LPA Williams interviewed Staff #1 (S1), who stated that Resident #1 (R1) was provided an eviction notice on January 9th 2022 for non-compliance of the facility rules. S1 stated that facility staff have spoken with R1's family members regarding R1's aggressive behaviors and have documented all incidences. S1 stated that R1 requires higher level of care and has reached out to another licensed facility who has agreed to accept R1 into their facility. S1 stated that R1 consented to being placed at another facility located in San Bernardino, CA. LPA Williams interviewed R1 who stated that when approached by facility staff regarding being placed at another facility, R1 stated that they wanted to speak to family members first. LPA Williams interviewed Family Member #1 (FM1) and Family Member #2 (FM2) who both stated that they felt they had no choice but to have Unsubstantiated R1 placed at another facility. LPA Williams reviewed documentation from S1, which appeared to be an eviction letter dated January 9th 2022. LPA Williams also reviewed documentation, such as R1's physician's report, which did not indicate R1 displayed aggressive behaviors. Documentation from other agencies also indicated that R1 did not display aggressive behaviors. LPA Williams reviewed the facility's rules which listed physical and verbal abuse as grounds for eviction from the facility. LPA Williams reviewed several incident reports which stated that R1 became aggressive with other residents in the facility and staff. Due to conflicting interviewee statements and lack of evidence to corroborate the allegation, the allegation is unsubstantiated. Based on evidence obtained during today’s visit, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning 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 (LIC 9099) was discussed and a copy was provided to Wang at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 8, 2022 · control 18-AS-20220203164419

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to conduct a required annual inspection, with an emphasis on infection control, due to the COVID-19 pandemic. LPA Williams identified herself to Administrator, Jin Wang, who was also informed of the purpose of the visit. During the inspection, LPA Williams interviewed Wang regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA Williams observed appropriate postings in the facility, including COVID-19 symptoms postings and visitation policies, which were in accordance with the Department's guidelines. LPA Williams observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA Williams observed that the facility staff were wearing face coverings. 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 a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. Furthermore, LPA Williams observed that the facility appeared to be meeting operational requirements. LPA Williams observed that all utilities and appliances were functioning properly and all passageways clear of obstruction, including emergency exits. The facility was equipped with sufficient food supply and emergency supplies. All areas of the facility, including client bedrooms and restrooms, appeared clean and in good repair. LPA Williams observed that medications and dangerous objects were kept inaccessible to clients in care. LPA Williams observed no apparent health and safety risks at the time of visit. Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was provided to Wang at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Feb 8, 2022