Aaspen Village Care III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Amanda Roberts, House Manager and Marlene Rasmussen'niesen, facility staff and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (23) with a current census of (12). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. The hot water temperature in residents' bathrooms measured 108 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Ombudsman poster and facility license. LPA observed disinfectants and cleaning solutions were stored in an unlocked cabinet underneath the kitchen sink and in a unlocked cabinet in the laundry room. LPA observed oxygen tanks without posted "No Smoking-Oxygen in Use” signs in the areas of oxygen use. The facility was not maintained free of incontinence odors. Yards/Outside: Outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility is enclosed with self-latching gates. Outdoor shaded area is sufficient for resident activities. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Care & Supervision: Facility has 24-hour care staff. Staff working at the facility have criminal record clearances or exemptions through the Department. Record Review: (4) resident files reviewed were observed to be complete. (4) staff files were reviewed. LPA observed facility did not maintain documentation of staff #1's (S1's) Dementia training. Facility did not maintain documentation of staff #2's (S2's) health screening and examination results. Facility did not maintain proof of liability insurance on file. Facility did not maintain record of last emergency drill on file. Facility did not maintain record of a emergency and disaster plan. Medical Related Services: All medication is centrally stored and kept in a locked in a cabinet. Based on observations and record review, deficiencies were cited during today's visit and a plan of correction was discussed. An exit interview was conducted where this report was discussed and a copy provided to facility staff at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 27, 2023

The state marks this report as 12 pages; the online copy we transcribed has 11. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide resident with a breathing treatment Staff are not providing resident's authorized representatives with information regarding resident Staff is being belligerent in the presence of resident Staff are not meeting residents needs

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to continue the complaint investigation. LPA met with Amanda Roberts, House Manager and discussed the purpose of the visit. Regarding the allegation staff did not provide resident with a breathing treatment, there is not enough evidence to corroborate this allegation. Regarding the allegation, staff are not providing resident's authorized representatives with information regarding resident, Administrator and staff interviewed deny not providing resident’s authorized representatives with information regarding resident. Residents interviewed deny that staff have not provided their authorized representatives with information about them. Unsubstantiated Regarding the allegation, staff is being belligerent in the presence of resident, Administrator and staff interviewed deny being belligerent in the presence of any residents. Residents interviewed deny that staff have been belligerent in their presence. Regarding the allegation that staff are not meeting resident’s needs, Administrator and staff deny not providing residents with their daily needs and services. Residents interviewed deny that staff are not meeting their care needs, in addition all residents interviewed stated that they feel safe and comfortable at the facility. Based on observations, interviews and document review, there is not enough evidence to corroborate the allegations, therefore, the allegations are Unsubstantiated. 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 was discussed and a copy with appeal rights was provided to the House Manager at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 18, 2023 · control 56-AS-20230227155936

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Magda Malcore conducted a case management visit based on deficiency observed during complaint investigation #56-AS-20230227155936. LPA met with Amanda Roberts, House Manager and discussed the purpose of the visit. LPA review of staff records reveal Staff #1 (S1) does not have the proper background clearance. LPA determined through Guardian system records that S1 did not have a criminal record clearance and application was closed in 2021. Facility personnel report shows S1’s start date as 9/20/2021. Civil penalties are being accessed today for not ensuring staff had proper clearance or exemption prior to working for the facility. A exit interview was conducted and a copy this report with appeal rights was provided to the House Manager at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 18, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Aug 19, 2023

87355 Criminal Record Clearance (e) all individuals subject to criminal record review…shall prior to working…in a licensed facility: (1) obtain California Clearance or a criminal record exemption as required by the Department...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure a criminal record clearance was obtained for Staff #1 (S1) prior to working at the facility, which poses an immediate Health, Safety, or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2023

Plan of correction: Administrator shall submit a letter of understanding of regulation cited and understanding that staff shall not return to the facility until staff has been cleared to the licensing agency by POC date.

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Amanda Robert (Tucker). Licensee was not at the facililty at the time of the visit, LPA contacted Administrator Christopher Tanabe by telephone and discussed the purpose of the visit. LPA conducted interviews with facility staff, resident #1 (R1), outside parties, obtained and reviewed facility file documents. R1 was sent the hospital due to a fall and then transferred to a nursing facility. R1 was discharged back to facility residence on 4/11/23. Upon R1s return to the facility residence, a staff member informed R1s driver that the resident could not return back into the facility and R1 had to be transported back to the nursing facility. Interview with the Administrator admitted that they refused to take R1 back into the facility residence due to the facility is unable to provide a higher level of care for R1. R1 is currently still at the nursing facility awaiting to be transported back to the facility residence. Substantiated The licensee did not follow Title 22 Regulation procedures on evictions by refusing to allow R1 into the facility residence; this poses a potential health and safety risk to residents in care. Based on file review and LPA’s interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated per California Code of Regulations, Title 22, Division 6. Deficiency is being cited on the attached LIC9099D. An exit interview was conducted where these reports (LIC9099 and LIC9099D) and appeal rights were discussed and provided to the Ashley Roberts (Tucker).the state’s words, verbatim · CDSS document, Apr 14, 2023 · control 56-AS-20230412104800

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Apr 17, 2023

87468.2 Additional Personal Rights… (a)In addition…residents…rights(20) To be protected from involuntary transfers, discharges, and evictions. A licensee …shall comply with…eviction and relocation protection for residents, this requirement is not met as evidenced by: On 04/11/23, R1 was discharged from the hospital and the licensee refused R1 back into the facility due the facility is unable provide a higher level of care for R1.the state’s words, verbatim · CDSS document, Apr 14, 2023

Plan of correction: Licensee to accept resident (R1) back into the facility. Licensee to review section cited and 87224 Eviction procedures and submit a statement of understanding by POC date.

Allegation investigated: Staff interferes with resident visiting. Staff will not give resident's conservators requested medical/facility documents. Staff do not maintain facility in good repair.

Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to initiate and deliver findings for the above complaint allegations. LPA met with Facility Manager Amanda Tucker and explained the reason for the visit. During today’s visit, LPA toured the facility, conducted interviews with residents and staff, reviewed and was provided facility documents. For allegation, Staff interferes with resident visiting: Upon arrival to the facility, LPA observed two (2) handwritten postings, one (1) on the front entry door and one (1) above the visitor sign in/sign out area that stated, “No visitors during mealtimes: Lunch 11:30 am to 12:30 pm Dinner: 4:30pm to 5:30pm.” During interviews conducted, LPA was informed that staff put the new visitor rule in place around the beginning of January 2023. Substantiated For allegation, Staff do not provide resident with clean linen: During facility tour, LPA observed the residents to have visible clean linens. During interviews conducted, LPA found that the facility washes the resident’s linens two (2) to three (3) times a week. The residents’ linens will be washed more often by staff if needed. For allegation, Staff do not change resident's diaper in a timely manner: During interviews conducted, LPA found that residents diapers are changed every two (2) hours. The resident’s diapers will be changed more often as needed. For allegation, Staff do not allow families to be bring residents food: During interviews conducted, LPA found that residents families are allowed to bring food to the facility. The facility just requests that visitors and families only provide food to the resident they are visiting due to residents having different dietary needs. Based on the evidence gathered during today’s investigation, the four (4) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations 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 (LIC9099) was discussed and provided to Facility Manager Amanda, along with a copy of the appeal rights. During document review, LPA found that the admissions agreement for the facility states that visitors are allowed from 8:00 am to 7:00pm. The facility not allowing visitors during a reasonable time frame poses a potential health, safety, or personal rights risk to persons in care. For allegation, Staff will not give resident's conservators requested medical/facility documents: During interviews conducted, LPA was informed that the facility thought that Resident R1’s conservator only oversees R1’s estate. During document review, LPA found that R1’s conservator oversees both estate and person for R1. LPA found that R1’s conservator has access to R1’s medical documents and facility documents. The facility denying requested documents to R1’s conservator poses a potential health, safety, or personal rights risk to persons in care. For allegation, Staff do not maintain facility in good repair: During facility tour, LPA found that there were exposed wires from a broken call button behind the bed in bedroom number eight (8) which poses a potential health, safety or personal rights risk to persons in care. Based on the evidence gathered during today’s investigation, the three (3) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met. During today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Facility Manager Amanda, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Jan 12, 2023 · control 56-AS-20230109110614

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Jan 14, 2023

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. Based on observation, interview and record review, the licensee did not comply with the section cited above evidenced by adding a facility rule that’s not in the admissions agreement that prevents residents from having visitors during mealtimes which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: The licensee has agreed to read regulation 87468.1 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to train staff of the approved admissions agreement visiting hours. The licensee has agreed to remove the handwritten postings stating visitors are not allowed during mealtimes. The POC is due by 1/14/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Jan 14, 2023

87506 Resident Records. (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. Based on interview and record review, the licensee did not comply with the section cited above evidenced by denying resident records to a resident’s legal conservator who is appointed for estate and person which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: The licensee has agreed to read regulation 87506 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to train staff on resident records and has agreed to provide LPA proof that the legal conservator was given the documents requested. The POC is due by 1/14/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 26, 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 and well-being of residents, employees and visitors. Based on observation and interview, the licensee did not comply with the section cited above evidenced by having exposed wires from a broken call button behind the bed in bedroom number eight (8) which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: The licensee has agreed to read regulation 87303 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to repair the call button and send LPA a photo once it is repaired. The POC is due by 1/26/2023.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit to follow up on an incident reports sent to licensing dated on 6/25/22, 7/22/22, and 7/23/22. The incidents involve six (6) residents that were missing narcotic medications. LPA met with Administrator Christopher Tanabe and explained the reason for the visit. LPA Gardner reviewed medications, medication logs, and conducted interviews with staff. LPA Gardner found that the Administrator has interviewed staff members who were on shift when the medication went missing. The Administrator had each staff member write down a written statement of what happened on the days in question. The Administrator informed state licensing of each incident and filed police reports for each incident. There are cameras that are in the process of being installed in the facility. The facility is going to ensure there is only one set of keys for the medication cabinet per shift. The facility is going to create a sign in/sign out sheet for the medication cabinet keys. As of today, 7/29/2022, the Administrator is unsure of where the narcotic medication is at and/or who took the narcotic medication. The facility will be receiving a citation for not supervising the staff and not establishing polices to ensure the residents medications do not go missing. The facility will also be receiving a citation for not providing medication safety and policy training to ensure staff has the knowledge and skill required to provide resident care. Additionally, during today’s visit, LPA Gardner found unlocked medication in the kitchen on top of the microwave, in an unlocked kitchen cabinet, and on top of the medication cabinet. This facility will be issued a citation for not locking the medication. Based on the observations made during today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809, LIC 809D, and appeal rights were discussed and provided to Administrator Christopher Tanabe.the state’s words, verbatim · CDSS document, Jul 29, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205(a) · Plan of correction due date: Jul 30, 2022

87205. Accountability of Licensee Governing Body. (a)The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement was not met based on interviews and documentation review. The licensee did not comply with the section cited above by not supervising the staff and not having polices in place to ensure the residents medications do not go missing.the state’s words, verbatim · CDSS document, Jul 29, 2022

Plan of correction: The licensee has agreed to read regulation 87205 entirely and send LPA a self-certify letter via email, fax, or post mail that the regulation was read and understood. The licensee has agreed to send a written plan of how the medication will be supervised to ensure residents medications do not go missing.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Jul 30, 2022

87465. Incidental Medical and Dental Care. (h)The following requirements shall apply to medications which are centrally stored:(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met based on observation. The licensee did not comply with the section cited above by having unlocked medication in the kitchen on top of the microwave, in an unlocked kitchen cabinet, and on top of the medication cabinet.the state’s words, verbatim · CDSS document, Jul 29, 2022

Plan of correction: The licensee has agreed to read regulation 87465 entirely and send LPA self-certify letter via email, fax, or post mail that the regulation was read and understood. The licensee has agreed to lock the medications in the medication cabient.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(e) · Plan of correction due date: Aug 12, 2022

87411.Personnel Requirements - General.In facilities licensed for sixteen (16) or more, the requirements of Section 87411(d) shall be met with planned on the job training program that utilizes orientation, skill training and continuing education. This requirement was not met based on interview with Administrator admitting the staff had not been trained on medication safety and policies. The licensee did not comply with the section cited above by not training the staff on medication safety and polices to ensure staff has the knowledge and skill required to provide resident care.the state’s words, verbatim · CDSS document, Jul 29, 2022

Plan of correction: The licensee has agreed to read regulation 87411 entirely and send LPA self-certify letter via email, fax, or post mail that the regulation was read and understood. The licensee has agreed conduct a medication training with the staff. The licensee has agreed to send LPA proof that a medication safety and policy training has been scheduled. The license has also agreed to send LPA proof that the class was completed.

Allegation investigated: Staff speak inappropriately to resident in care.

Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a complaint investigation. LPA Brown identified herself and discussed the purpose of the visit and the elements of the allegation(s) with House Manager Crystal Green. The investigation was conducted by LPA Melody Brown. The investigation consisted of interviews with relevant parties. The first allegation indicates that staff speak inappropriately to resident in care. LPA Brown interviewed Administrator Christopher Tanabe (S1) regarding this allegation and the events in which the allegation is based upon. Administrator Tanabe confirmed that S5 speaks inappropriately to residents. Administrator Tanabe also added that their investigation indicated that Staff 5 (S5) was very rude, bossy and doesn’t want to do anything at the facility. Administrator Tanabe also reported that S5 was terminated as a result of their investigations. Substantiated Based on interviews conducted with staffs and residents , the above allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.the state’s words, verbatim · CDSS document, Sep 29, 2021 · control 18-AS-20210924133704

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Sep 30, 2021

Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met by Based on interviews, the Licensee did not provide at least one resident (R1) with dignity in thier relationships with staff (S5) as observed by Licensee as being rude, bossy and speaking inappropriately to R1. This poses a potential personal rights violation to R1.the state’s words, verbatim · CDSS document, Sep 29, 2021

Plan of correction: Licensee agrees movng forward to monitor their relationship with rsidents and to hold themselves to a professional matter at all times. No further plan of correction needed.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA Brown was greeted and granted entrance by House Manager Crystal Green and LPA Brown explained the purpose of today's visit. House Manager Green accompanied LPA Brown on a tour of the inside and outside of the facility. During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper Covid-19 signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient 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, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. 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 to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to House Manager Green.the state’s words, verbatim · CDSS document, Sep 29, 2021