Heritage Court Assisted Living

Allegation investigated: Staff do not maintain facility in a clean and sanitary condition. Facility is in disrepair.

On 11/06/2023 at 09:37 AM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott arrived unannounced at the facility to deliver findings for the allegations listed above. LPAs Brown and Wolcott were greeted and granted entry by a staff at the reception area and were informed that Assistant Administrator Lauren Calvani was on a meeting and will be informed of the visit. LPAs Brown and Wolcott explained the purpose of the visit. The investigation consisted of observation, interviews and a review of pertinent documentation. Through the information gathered during the investigation, it was confirmed by observation, documents review and interviews that the staffs do not maintain the facility in a clean and sanitary condition. Interviews with Resident #5 (R5), Resident #6 (R6), and Resident #8 (R8) indicated that their rooms gets clean once per week, staff missed days cleaning residents room and nobody cleans their room if the housekeeping staff's off. R10 reported to LPA Brown that no staff cleans their room and they had to clean it themselves. ***Continuation in LIC9099C*** Substantiated Interviews with Staff #4 (S4) indicated that housekeeping staff should be cleaning residents room everyday. Staff #6 (S6) reported to LPAs Brown and Wolcott that only one (1) housekeeping staff works at the facility per day and Staff #7 indicated that First (1) floor of the facility's not clean and sanitary. In addition, interviews with S6 revealed that Staff #8 (S8) who was assigned to clean the first floor of the facility just sits, don't clean and they reported S8 to the housekeeping supervisor but the housekeeping supervisor did not do a thing to address the issue. During the facility visit on 11/06/2023, LPAs Brown and Wolcott toured the facility and observed that residents unkept rooms, not clean rooms, dirty carpets located at the first floor of the facility. Deficiencies will be issued as this pose potential health, safety and personal rights risks to residents in care. The second allegation indicates Facility is in disrepair. LPAs Brown and Wolcott obtained evidence to corroborate the allegation. Interviews with Resident #2 (R2) indicated that the toilet was clogged in Room #103 and flooded Room #104 to Room #119, Resident #10 (R10) reported that their air conditioning unit was leaking and there's water on the floor. Interviews with Staff #4 (S4) indicated that Their Medical Room ceiling was collapsing and their sink was dripping. Moreover, Staff # 6 (S6) reported to LPAs Brown and Wolcott that the bathroom located near the facility's Dining Room was clogged for three (3) to four (4) months now. Also, Staff #7 (S7) reported to LPAs Brown and Woilcott sink leaking, and problem with the facility's vent. During the visit, LPAs Brown and Wolcott observed broken closet door in Room #117. LPA Brown reviewed compliance history and observed that the facility’s issued the same deficiency for the facility not being clean and sanitary and in good repair on 07/14/2023. Civil Penalty was assessed for repeat violations within a 12-month period in the amount of $250.00 per citation and will continue to be assessed of $100.00 per day per citation until corrected. Based on LPAs Brown and Wolcott's observations, interviews and records review, the preponderance of evidence standard has been met, and therefore the above allegation of Staff do not maintain facility in a clean and sanitary condition (Allegation #1), and Facility is in disrepair (Allegation #2) were 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. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is cited on the attached LIC9099D. ***Continuation in LIC9099C *** An exit interview was conducted where this report (LIC9099), LIC9099D,LIC421FC and Appeal Rights were discussed and provided to Assistant Administrator Lauren Calvani. observe mold in Resident #1 (R1) room and during the facility visit on 11/06/2023, LPAs Brown and Woldcott toured the facility and did not observe mold on residents rooms. Based on the evidence, the allegation that Facility has mold is 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 Assistant Administrator Lauren Calvanithe state’s words, verbatim · CDSS document, Nov 6, 2023 · control 56-AS-20230731093552

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 20, 2023

87303 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... This requirement was not met as evidenced by: Based on observation, interview and record review, the Licensee did not comply with the section cited above by not maintaining the facility clean and sanitary and not having housekeeping staff clean residents bedrooms daily which pose potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2023

Plan of correction: Licensee stated to add one (1) Housekeeping staff per day to make sure all residents rooms are clean everyday and will submit proof of updated Housekeeping Staff Schedule to LPA Brown at POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 20, 2023

87303 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... This requirement was not met as evidenced by: Based on observation, interview and record review, the Licensee did not comply with the section cited above by not having the facility bathroom near the dining room in good repair for 3 to 4 months now and the closet door in Room #117 in disrepair wich pose potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2023

Plan of correction: Licensee stated to repair the bathroom near the Dining Room, broken closet door in Room #117 and submit proof to LPA Brown at POC due date.

Type of visit: Case Management - Deficiencies

On 11/06/2023 at 09:37 AM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott arrived unannounced at the facility to initiate a Case Management Visit. LPAs Brown and Wolcott explained the purpose of the visit. The investigation consisted of interviews and a review of pertinent documentation. Per review of R1's Physician Report (LIC602), LPAs Brown and Wolcott observed that the facility failed to complete the required annual medical assessment, reappraisal and reassessment done for R1's dementia care needs. LPA Brown informed Assistant Administrator Lauren Calvani that deficiency will be issued as this pose potential health, safety and personal rights risk to residents in care. An exit interview was conducted where this report LIC809, 809D and Appeal Rights were discussed and provided to Assistant Administrator Lauren Calvani.the state’s words, verbatim · CDSS document, Nov 6, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(5) · Plan of correction due date: Nov 20, 2023

87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of...This requirement is not met as evidenced by: Based on interviews & records review, the Licensee did not comply with the section cited above by failing to complete the required annual medical assessment, reappraisal and reassessment done for R1's dementia care needs which pose potential health, safety and personal rights risks to resident in care.the state’s words, verbatim · CDSS document, Nov 6, 2023

Plan of correction: Licensee stated to complete R1's updated LIC602 and submit proof to LPA Brown at POC due date. The Licensee stated to train all staff on CCR 87705(5) and submit proof of Training Log to LPA Brown at POC due date.

Allegation investigated: Personal Rights

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Assistant Administrator Lauren Calvani and explained the purpose of the visit. First allegation, Personal Rights. During facility visit when LPA asked facility Administrator for Resident #1 records it was discovered that Resident #1 is not a current resident at the facility but rather a resident at a Special Treatment Program (STP), located at building “A”. Facility Administrator at “Heritage Court Assisted Living” confirmed to LPA that Resident #1 (R#1), was never a resident at their facility. Based on the available information, LPA found that the complaint allegation is Unfounded. Unfounded: A find of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was discussed, and a copy was provided to Assistant Administrator Lauren Calvani Unfoundedthe state’s words, verbatim · CDSS document, Oct 27, 2023 · control 56-AS-20231026150321

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff do not ensure facility is kept free of pests for residents in care.

On 07/13/2023 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to deliver findings for the allegation listed above. LPA Brown was greeted and granted entry by a staff at the reception area and Assistant Administrator Erika Montoya was contacted and LPA Brown explained the purpose of the visit. The investigation consisted of observation, interviews and a review of pertinent documentation. Through the information gathered during the investigation, it was confirmed by observation, documents review and interviews that there are still roaches in the facility after cleaning and spraying for them was conducted. Although the facility is taking action for the roaches, as Assistant Administrator Montoya indicated, it appears that there is not sufficient treatment being done by the facility’s contracted exterminator to aggressively rid the roaches. Also, Assistant Administrator Montoya reported that the facility will have a sufficient follow up to their contracted exterminators to control the roaches in the building. Interviews with staff also indicated knowledge of roaches at the facility. *** Cont. in LIC9099C *** Substantiated LPA Brown toured the facility with Assistant Administrator Montoya last 07/12/2023 at around 10:15 AM and LPA Brown observed bugs traps placed at residents’ rooms and at Assistant Administrators’ Montoya’s office as well. Also, during the visit, Assistant Administrator Montoya reported that they are aware of the roaches at the facility, and they already drafted an agreement with their contracted exterminator but still pending approval from their management. LPA Brown requested for the facility’s exterminator monthly services invoices record and LPA Brown observed monthly services conducted but per Assistant Administrator Montoya’s statement to LPA Brown that the contracted exterminator is spraying the outside of the facility and whatever the reported issue was. LPA Brown recommended to Assistant Administrator Montoya that in addition to spraying the outside of the facility, the contracted exterminator must sprayed/serviced all rooms, not just selected resident rooms. Assistant Administrator Montoya reported that they have a plan with the contracted exterminator to address the issue that is for signature by their management already which is to sprayed/service not selected room, but all rooms must be sprayed. Based on observation and interviews, the allegation of Staff do not ensure facility is kept free of pests for residents in care 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 conducted and a copy of this report, LIC9099, LIC9099D and appeal rights was discussed and provided to Assistant Administrator Erika Montoya.the state’s words, verbatim · CDSS document, Jul 13, 2023 · control 56-AS-20230705120759

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 14, 2023

87303 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... This requirement was not met as evidenced by: Based on observation, interview and record review, the Licensee did not comply with the section cited above by not aggressively addressing the roaches’ issue at the facility which poses immediate health, safety and personal rights risks to resident in care.the state’s words, verbatim · CDSS document, Jul 13, 2023

Plan of correction: Licensee stated to call exterminator within 24 hours to have exterminator services performed on the inside and outside of the facility and a plan of procedure shall be submitted to LPA Brown no later than COB 07/14/2023 regarding the roaches observed at the facility. LPA Brown will also receive all receipts of services for the roach’s service/treatment once performed no more than 24 hours after services performed.

Type of visit: Case Management - Deficiencies

On 07/12/2023 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility for a Case Management Deficiency visit. LPA Brown identified herself and discussed the purpose of the visit with Assistant Administrator Erika Montoya. During the facility on 07/12/2023, LPA Brown requested a copy of LIC500 Personnel Report from Assistant Administrator Erica Montoya and per LPA Brown’s review, LPA Brown observed Staff # 7 (S7) and Staff # 8 (S8) were working at the facility without criminal background clearance. Assistant Administrator Erika Montoya confirmed with LPA Brown that S7 had been employed since 06/2006 and S8 had been employed since 07/2021. LPA Brown explained to Assistant Administrator Montoya that deficiency will be issued as this pose immediate health, safety and personal rights risks to residents in care. A civil penalty of $500.00 was assessed per individual for S7 and S8 working at the facility without criminal background clearance. The civil penalty will continue to be assessed of $100.00 per day until corrected during the visit. An exit interview was conducted where this report, LIC809, along with LIC809D, LIC421BG and Appeal Rights were discussed and provided to Assistant Administrator Erika Montoya.the state’s words, verbatim · CDSS document, Jul 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jul 13, 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... (1) Obtain a California clearance... This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing S7 and S8 to work at the facility without criminal backround which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 12, 2023

Plan of correction: Licensee stated to train all staff on CCR 87355(e)(1) and submit proof of Training Log to LPA Brown by POC due date. Licensee stated to remove S7 and S8 immediately and submit proof of criminal background clearance to LPA Brown by POC due date.

Type of visit: Collateral

Licensing Program Analyst (LPA) Anna Bueno made an unannounced collateral visit to this facility in relation to complaint control number: 18-AS-20200724130142. LPA met with Wellness director Janet Nelson and explained the nature of the visit. LPA conducted witness interviews and obtained relevant documents. A copy of this report was reviewed with and provided to assistant administrator Erika Montoya at the conclusion of this visit.the state’s words, verbatim · CDSS document, Apr 3, 2023

Allegation investigated: Resident is being overcharged.

Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to the facility to initiate the investigation of and deliver findings to the above mentioned allegation. LPAs identified themselves to assistant administrator Erika Montoya and discussed the purpose of the visit and elements of the allegation. The investigation included resident and staff interviews, and records review. The allegation is Resident is being overcharged. Review of LIC602A, Physician's Report, LIC603, Preplacement Appraisal, and facility needs and service care plan show that Resident 1 (R1) requires medication management and assistance with self-care activities. LPAs reveiwed admissions agreement that shows R1 agreed to grooming and bathing services. LPAs reveiwed R1 payment history from 7/1/19 through 12/31/22 and found that bathing assistance and medication management were only charged on July 2019, August 2019, and October 2019. This allegation is therefore UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was discussed, and a copy provided to Erika Montoya. Unfoundedthe state’s words, verbatim · CDSS document, Jan 12, 2023 · control 18-AS-20220111102333

Allegation investigated: Staff leave resident in bed for extended periods of time.

Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to the facility to initiate the investigation of and deliver findings to the above mentioned allegation. LPAs identified themselves to assistant administrator Erika Montoya and discussed the purpose of the visit and elements of the allegation. The investigation included facility observations, resident and staff interviews, and records review. It is alleged that Staff leave resident in bed for extended periods of time. Interviews with residents revealed that staff check on the residents regularly and residents use a call button for assistance. Records reviewed show that Resident 1 (R1) likes to be in bed most of the time. Interview with R1 confirmed they periodically go out to the community and that staff move them from their bed when requested. LPAs observed sufficient staff working with residents during today's visit. This allegation is therefore unsubstantiated. A 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 Erika Montoya and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 12, 2023 · control 56-AS-20230103105041

Allegation investigated: Facility staff are not preventing residents from smoking inside facility.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the investigation of and deliver findings to the above mentioned allegation. LPA identified herself to assistant administrator Erika Montoya and discussed the purpose of the visit and elements of the allegation. The investigation included facility observations, resident and staff interviews, and records review. It is alleged that the facility is not doing anything regarding residents who smoke inside their rooms. During today's visit, LPA did not observe any residents smoking in the designated smoking area but observed a resident smoking in the parking lot, at least 20 feet away from all facility exit doors. LPA did not smell cigarette smoke in the facility. Resident interviews confirm that the facility has a no smoking indoors policy. Staff interviews reveal that no resident has been observed smoking indoors however reports were received from staff and residents. Staff further state that they speak to the resident in person to remind them of the no smoking policy. Records reviewed list the no smoking facility listed in the resident house rules and policies and procedures. Based on the above allegations, this complaint allegation is unsubstantiated. ***SEE LIC9099-C*** Unsubstantiated A 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 Erika Montoya and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2022 · control 56-AS-20221206112206

Allegation investigated: Staff are not following COVID guidelines and protocols.

Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegation. LPA Gardner met with Assistant Administrator Ericka Montoya and explained the reason for the visit. At the time of the visit, there were fifty (50) residents present. During today’s visit, LPA toured the facility, reviewed facility documents, interviewed staff members, and interviewed residents. For allegation, Staff are not following COVID guidelines and protocols: LPA found that the facility has a COVID-19 mitigation plan on file with State Licensing. The plan in place follows Community Care Licensing Division guidelines for COVID-19 testing, quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a full thirty (30) day supply of Personal Protective Equipment (PPE). All staff and visitors are given a mask to wear upon entry into the facility. Unsubstantiated Upon entry a temperature and symptom screening is completed for staff and residents. If a staff member has a temperature or symptoms, they are not allowed to enter the facility. The staff will be tested for COVID-19 and will be sent home to quarantine if they test positive. The facility staff monitors residents for COVID-19 symptoms. If a resident is experiencing symptoms and or tests positive for COVID-19, they are isolated in their bedroom. If there is a positive resident and or staff case in the facility, the facility completes a mass COVID-19 testing of all staff and residents. Based on the information found during today’s investigation, the allegation listed above is deemed 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. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Assistant Administrator Ericka Montoya, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Nov 22, 2022 · control 56-AS-20221118090320

Allegation investigated: Facility staff failed to dispense resident's medication as prescribed Facility staff abandoned resident

Licensing Program Analyst (LPA) Natalie Ibarra conducted an unannounced visit to the facility to deliver findings for the above allegations. LPA met with Assistant Administrator Erika Montoya and explained the purpose of today’s visit. Investigation consisted of interviews with pertinent parties and records review. The first allegation indicates facility staff failed to dispense resident's medication as prescribed. Interviews with Staff #1 (S1) and Staff #2 (S2) stated that medication was being dispensed to Resident #1 (R1) as prescribed. LPA reviewed R1’s MARs and observe medication was being administered as per doctor orders. Unsubstantiated The second allegation indicates facility staff abandoned resident. Interviews with S1 and S2 stated that R1 was not abandoned. S1 stated that the facility was not able to meet R1’s needs and wanted R1 to be evaluated at a psych ward before readmitting. S1 provided hospital social worker with the facility that was willing to take R1 and had an opening. LPAs reviewed R1’s hospital progress notes and social worker notes. Progress note on 2/2/21 states patient has no new symptoms and is awaiting in-patient psych facility placement. Social service notes from 1/29/21 states social worker got a call stating MD wants patient to be placed at a psych facility. Based on the information obtained, the allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegations 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, and a copy of this report was discussed and provided to Assitant Administrator Erika Montoya.the state’s words, verbatim · CDSS document, Nov 9, 2022 · control 18-AS-20210203164702

Allegation investigated: Staff did not assist resident with medications as needed. Facility did not coordinate care with hospice agency. Staff did not meet resident's bathing needs. Facility is malodorous. Facility is not clean.

Licensing Program Analysts (LPAs) Natalie Ibarra and Victoria Chitgian made an unannounced visit to the facility to deliver findings for the above allegations. LPAs met with assistance administrator Erika Montoya and explained the purpose fo today's visit. The investigation consisted of interviews with pertinent parties and records review The first allegation indicates staff did not assist resident with medications as needed. Interiviews with Staff #1 (S1) and Staff #2 (S2) indicated that Resident #1 (R1) medications were being administered. LPAs reviewed medication log for R1 and observed medications were being administered to R1 including eye drops and topical creams prescribed by doctor. S4 stated hospice company would provided lot of topical creams and eye drops at once due to bottles being small The second allegation indicates facility did not coordinate care with hospice agency. Interviews with S1 and S2 stated facility was coordinateing with hospice facility. S4 stated facility is always in communication with hospice. Interview with Bridge Hospice Executive Director stated that per visit notes facility was coordinating care with hospice. Unsubstantiated The third allegation indicates staff did not meet resident's bathing needs. Interviews with S1, S2, S3, and S4 stated that when a resident is on hospice, hospice will take over bathing residents. S2 and S4 stated baths were being administered by hospice company. Interview with Bridge Hospice Executive Director stated baths were being provided per aid nurse notes. LPA review aide care notes from Bridge Hospice that stated complete bed baths were to be done every visit per instructions. The fourth allegation indicates facility is malodorous. LPAs Ibarra and Chitgian toured the facility, including a sample of resident rooms, common restrooms, activity room , and dining area. LPAs did not observe any foul odors. Interviews with S1 and S3 denied facility is odoriferous The fifth allegation indicates facility is not clean. LPAs Ibarra and Chitgian toured the facility, including a sample of resident rooms, common restrooms, activity room , and dining area. LPAs did not observe facility to be unclean. Interviews with S1 and S3 denied facility is not kept clean. Based on the information obtained, the allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegations 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, and a copy of this report was discussed and provided to Assistant Administrator Erika Montoya.the state’s words, verbatim · CDSS document, Nov 1, 2022 · control 18-AS-20210303152015

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natalie Ibarra made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA met with Assistant Administrator Erika Montoya. LPA Ibarra toured the facility and went over COVID-19 best practices for infection control and prevention with the Assistant Administrator. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The entrance of the facility has a check in process for visitors that includes a vaccination verification/negative COVID test check, a temperature check, and a symptom check. The staff working at the facility were all properly wearing face mask. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPA Ibarra requested to inspect the facility's Personal Protective Equipment (PPE) supply. The facility has a full thirty (30) day supply of PPE such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer. LPA observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, the facility is meeting operational requirements. No deficiencies were cited during today’s visit An exit interview was conducted and a copy of this report was discussed and provided to Assistant Administrator Erika Montoya.the state’s words, verbatim · CDSS document, Sep 16, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain. LPA met with Assistant Administrator Erika Montoya who confirmed there is no active/suspected Covid-19 case and/or exposure in the community. LPA toured the facility with Montoya. The facility submitted a mitigation plan to Community Care Licensing (CCL) to mitigate the spread of COVID-19 in the facility. Single entry point at the skilled nursing facility lobby maintains the sign-in policy for universal entry screening. The facility also documents temperature and COVID-19 symptom checks for all visitors while residents are subject to regular observations for any change in condition. Continued weekly routine testing for staff is still observed. LPA observed all staff are properly fitted with face coverings. LPA Bueno and Montoya toured the facility’s common rooms and an empty private apartment currently housing Personal Protective Equipment (PPE) . LPA and Montoya observed COVID precautionary signages around the facility. Montoya verified that the smoke and carbon monoxide detectors and fire alarms are maintained by an outside vendor and was last serviced in 8/13/2021. Montoya confirmed that fire extinguishers are checked quarterly by a different vendor. Montoya stated that the facility also routinely monitors the detectors for functionality. LPA observed hand sanitizer throughout the facility, mostly situated by the elevator and exit doors. Montoya confirmed the facility has an adequate supply of cleaning and disinfectant provisions. Based on 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 also provided to Montoya at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Oct 25, 2021

Allegation investigated: Food Service inadequate. Facility has an odor. Resident furniture is in poor condition.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding allegations that the food service is inadequate, facility has an odor and resident furniture is in poor condition. LPA met with administrator Jake Schlottman and toured facility kitchen. Facility provides a menu everyday and with alternate meals. Food is of good quality and nutritional value. Residents are allowed to ask for alternate meals that are not on the menu. Facility lobby was found to be clean and cool and free of odors. Resident #1 (R1) in question was interviewed and stated no complaints with furniture or condition of room. Based on the information obtained there is not enough evidence that food service is inadequate, facility has an odor and resident furniture is in poor condition. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 31, 2021 · control 18-AS-20210826084412

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: Facility is not following resident's doctor's orders. Facility is not properly maintaining resident's medical device.

Licensing Program Analysts (LPAs) Anna Bueno and Natalie Gayoso conducted an unannounced visit to the facility to follow up on a complaint investigation and deliver findings. LPAs met with Erika Montoya, Assistant Administrator. The investigation consists of staff and resident interviews and review of pertinent documents. The complaint alleges that 1: Facility is not following doctor’s orders and 2: Facility is not properly maintaining resident’s medical device. Interview with resident (R1) revealed that they have been prescribed a CPAP machine from a previous skilled nursing facility (SNF) and brought the machine to Heritage Court when they moved. R1 shared that two staff have assisted R1 with setting up the CPAP, cleaning the machine on multiple occassions, and using the recommended distilled water for the machine. R1 confirmed the bottle of distilled water that staff bought is still in R1’s room and that this facility has been following R1’s doctor’s orders regarding R1’s CPAP. These two allegations are therefore unsubstantiated per LPAs resident interview. Unsubstantiated A 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. No deficiencies have been cited during this visit. An exit interview and a copy of the report was given to Ms. Montoya.the state’s words, verbatim · CDSS document, Jul 1, 2021 · control 18-AS-20210222101836

Allegation investigated: Residents are left in soiled diapers for a long period of time.

Licensing Program Analysts (LPAs) Natalie Gayoso and Anna Bueno conducted an unannounced visit to the facility to investigate the above allegations. LPAs met with Assistant Administrator Erika Montoya and explained the purpose of today's visit. The investigation consisted of interviews with staff and residents. The allegation indicates residents are left in soiled diapers for a long period of time. Interviews Staff #1 (S1) and Staff #2 (S2) stated staff checks every 2 hours on residents who require diapers and have not been left in soiled diapers for a long period of time. Interviews with residents confirmed that staff checks on residents every 2 hours. Residents also stated they have not been left in soiled diapers for a long period of time. Resident #2 (R2), Resident #6(R6), Resident #7 (R7) stated they will also call caregivers for diaper change as needed and staff does assist in a timely manner. Unsubstantiated Based on interviews the allegation is 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. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to the Ms. Montoya.the state’s words, verbatim · CDSS document, Jul 1, 2021 · control 18-AS-20210622160728

Allegation investigated: Facility accepted a resident with unstageable wound Facility failed to obtain medical attention for resident

Licensing Program Analysts (LPAs) Natalie Gayoso and Anna Bueno conducted a complaint visit to deliver findings regarding the above allegations. LPAs identified themselves and discussed the purpose of today’s visit and the elements of the above allegations with Assistant Administrator Erika Montoya. The Department conducted investigation of the allegations to include interviews and records review. The first allegation indicates facility accepted a resident with unstageable wound. Interviews with staff revealed the facility did accept Resident 1 (R1) on 1/15/21 who had a stage 4 wound. Interview with Staff 1 (S1) stated the facility is aware that they are not able to admit residents with stage 2 or higher wounds unless hospice is involved and is providing wound care. Interview with Staff 2 (S2) stated hospice care was already in place and coordinated prior to R1 being admitted to the facility, and services started the same day R1 was admitted. LPA was able to confirm that a hospice care plan was in place prior to resident moving in. LPA reviewed facility file and verified the facility has a hospice waiver for 7. Unfounded The second allegation indicates the facility failed to obtain medical attention for resident. Interview with S2 stated R1 received wound care up to three times a week from hospice and was assessed twice by wound specialist, Wound Pros, on 1/19/21 and 2/19/21. Review of records confirmed R1 was receiving wound care two to three times a week from hospice and a plan of care was provided by Wound Pros Based on the investigation the Department has found the allegations to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without reasonable basis. An exit interview was conducted and a copy of this report was provided to Ms. Montoya.the state’s words, verbatim · CDSS document, Jul 1, 2021 · control 18-AS-20210301133144