Terrace Gardens

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Paola Guerrero 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 Facility Administrator Dekki Mawikere and was granted entry to the facility. At the time of the visit there were two (2) staff, and six (6) residents present. LPA toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Dekki. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients 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 temperature check and a symptom check. 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 the facility for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, located in the hallway cabinet. The facility has a full thirty (30) day supply of PPE items such as gloves, face shields, gowns, disinfectant, surgical masks, N95 masks, and hand sanitizer. All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19. Based on the observations made 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 (LIC809) was discussed and provided to Facility Administrator Dekki Mawikere.the state’s words, verbatim · CDSS document, Dec 13, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to verify a proof of correction from an 8/16/2022 visit citation and to deliver an amended report of complaint control number: 56-AS-20220808090401. Complaint control number 56-AS-20220808090401 is SUBSTANTIATED and deficiency is being cited on this report's LIC809-D. LPA Bueno verified that the side gates are accessible from the outside and LPA viewed Resident 1's physician's order for PRN medications. A Letter of Deficiency Citations Cleared was issued to Administrator Mawikere on this day. Administrator Mawikere signed the amended LIC9099, LIC809, and LIC809-D. All reports, including aforementioned forms, appeal rights , and letter of deficiency citation cleared, were discussed with and copies were provided to Mr. Mawikere at the conclusion of today’s visit.the state’s words, verbatim · CDSS document, Sep 27, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(2) · Plan of correction due date: Oct 10, 2022

Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: As indicated on complaint number 56-AS-20220808090401, Resident 1 was found outside the facility and returned to this facility by a visitor.the state’s words, verbatim · CDSS document, Sep 27, 2022

Plan of correction: Licensee has installed a monitoring system outside the facility and audible signals for exit doors before today's visit. The correction was in place before this visit.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings for complaint number: 56-AS-20220808090401. LPA met with Dekki Mawikere, administrator, who was explained the purpose of today’s visit. During the complaint investigation, LPA Bueno found that both side gates are secured but one of the gates is locked. LPA also found that Resident 1 (R1) was receiving nonprescription PRN medication. This poses a potential risk for residents in care. Refer to LIC-809D for deficiencies cited. An exit interview was conducted where this report, LIC-809D, and appeal rights were discussed and provided to Mr. Mawikere.the state’s words, verbatim · CDSS document, Aug 16, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(l)(2) · Plan of correction due date: Aug 31, 2022

The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement was not met as evidenced by: LPA and Staff 1 viewed one of two side gates secured and locked with padlock. This poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2022

Plan of correction: Licensee shall keep both side gates secured but not locked in any capacity. If Licensee wishes to keep gates locked, Licensee shall submit proof to the Department that requirements as outlined in CCR Section 87705(l) no later that end of POC date, 8/31/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(b) · Plan of correction due date: Aug 31, 2022

If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement was not met as evidenced by: Administrator interview showed that Resident 1 is receiveing two nonprecription PRN medications. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2022

Plan of correction: Licensee shall submit written proof of Resident's physician's order for two nonprescription PRN medication no later than the end of POC date, 8/31/2022.

Type of visit: Required - 1 Year

Licensing Program Analysts Rohit Lama, Bernadette Allen, and Anna Bueno 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. LPAs identified themselves to Administrator, Dekki Mawikere, and discussed the purpose of the visit. Prior to entry, facility Staff #1 (S1) required LPAs to get temperature checks and ensured that LPAs were masked. Administrator stated that all staff and residents were fully vaccinated and there were no recent positive COVID test results nor were there any individuals currently with COVID symptoms. Inspection Tool was utilized, Mitigation plan was reviewed. Facility was further inspected and no deficiencies were noted. During the inspection, LPA Lama interviewed the Administrator pertaining to the facility's infection control measures and other health and safety concerns. LPA Lama observed necessary signs posted in the facility, including signs related to COVID-19, which were in accordance with the Department's guidelines. The Administrator stated that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. LPAs 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, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, 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 of residents, and properly caring for residents 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. 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 Dekki Mawikere at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Nov 16, 2021

Allegation investigated: Staff is filming residents without permission

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility to deliver findings on an open complaint with the above allegation (s). LPA Colvin identified herself and discussed the purpose of the visit and the elements of the above allegation with Administrator Dekki Mawikeri. Below is a summary of the findings: Regarding the allegation "Staff is filming residents without permission": The Department conducted investigation of the allegation to include interviews. The allegation is specific to facility staff having filmed a resident (R1) while R1 was receiving emergency services from paramedics. The Administrator and Licensee concede to the fact that on June 8, 2020 staff took photographs of R1 while R1 was receiving emergency services. Per the Administrator photographs were taken of R1at the family’s request. Administrator maintains that while photographs were taken, the staff did not take video. Due to lack of evidence regarding the existence of specifically video footage, the allegation "Staff is filming residents without permission" is UNSUBSTANTIATED. 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 Administrator Dekki Mawikeri and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 15, 2021 · control 18-AS-20200608131822

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting a follow-up visit regarding complaint (#18-AS-20200608131822). LPA Colvin met with Administrator Dekki Mawikeri and advised them of the purpose of the visit. During LPA Colvin's visit, LPA Colvin addressed the following issue which was discovered during the investigation: The complaint (#18-AS-20200608131822) that LPA Colvin investigated primarily revolved around an incident that occurred on 6/8/20 when paramedics were called due to a medical emergency regarding one of the residents at the facility. During LPA Colvin's review of Community Care Licensing's (CCL) record of reported incidents from this facility, LPA Colvin observed that CCL did not receive an Incident Report for 6/8/20. In fact, CCL has not received any Incident Reports or Death Reports from the facility since their opening in 2014. All unusual incidents (and deaths) which may pose a risk to a resident's health or safety (such as: calls to 911 or medical emergencies) are to be reported to CCL within 7 calendar days. Deficiency cited. Additionally, facility staff admitted in interviews that the previous staff member (S1) took photos of the residents (R1) who was receiving emergency medical care from the paramedics. It was confirmed that the facility does not have prior written permission from the resident or responsible party to have photographs taken. Deficiency cited. R1 passed away and was unable to be interviewed regarding consent for photographs. During today's visit, LPA Colvin observed that one of the staff members present (S2) was not associated to the facility. Additionally, the Administrator was unable to provide proof of background clearance for S2, as it was not in their file. According to previous interviews conducted by LPA Colvin, S2 has been working at the facility for 4 months. Deficiency cited. LPA Colvin will be assessing a civil penalty of $100 per day that S2 has worked at the facility without background clearance. Since it was reported to LPA Colvin that S2 has worked for 4 months and the facility does not have any records stating otherwise, LPA Colvin will issue penalties for the maximum of 5 days. $100 per day x 5 days = $500 in civil penalties being assessed today. Lastly, all staff files must contain pertinent records that reflect their eligibility to be employed at the facility. LPA Colvin was unable to confirm S2's background clearance due to the facility not having a copy of it in their file. Deficiency cited. LPA Colvin conducted an exit interview with Administrator Dekki Mawikeri, and a copy of this report, LIC809D, LIC421BG, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 15, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Oct 29, 2021

Additional Personal Rights of Residents in Privately Operated Facilities : (a) In addition to the rights listed...residents... ave all of the following personal rights: (1) To have...privacy in...medical treatment, personal care and assistance... This requirement was not met as evidenced by: Based on interviews, the Licensee did not comply with the above regulation with at least one resident (R1). Licensee stated that S1 took photos of R1 when paramedics responded to provide medical aid. Licensee does not have consent on file. This posed a potential personal rights violation to R1.the state’s words, verbatim · CDSS document, Oct 15, 2021

Plan of correction: Licensee agrees to obtain a written consent form from all residents and their responsible parties prior to taking any photographs of them. Licensee to provide LPA Colvin with Statement of Understanding by Plan of Correction date of 10/29/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a)(13)(B) · Plan of correction due date: Oct 29, 2021

Personnel Records : (a) The licensee shall ensure...records are maintained on...each employee. Each personnel record shall contain...: (13) For employees...(B) Documentation of either a criminal record clearance or a criminal record exemption... This requirement was not met by: Based on record review and interview, the Licensee did not comply with the above regulation with one staff member (S2). Licensee was unable to provide LPA Colvin with proof of clearance or transfer in S2's personnel file. This is a potential safety risk to all residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2021

Plan of correction: Licensee agrees to update S2's file to include all required documents. Licensee to submit Statement of Understanding to LPA Colvin regarding all documents required to be maintained in staff files. Statement to be submitted to LPA Colvin by Plan of Correction date of 10/29/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 18, 2021

Reporting Requirements: (a) Each licensee shall furnish to the licensing agency...the following:(1) A written report shall be submitted...within seven days...of any of the events specified ...(D) Any incident which threatens the welfare, safety or health of any resident... This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one incident. LPA Colvin observed that emergency services were called out to the facility on 6/8/20 but the facility never submitted an Incident Report to CCL. This was an immediate safety risk to all residents.the state’s words, verbatim · CDSS document, Oct 15, 2021

Plan of correction: Licensee agrees to review Title 22 Regulation Section 87211 regarding Reporting Requirements. Licensee to Statement of Understanding to LPA Colvin regarding reporting incidents to CCL by Plan of Correction date of 10/18/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Oct 18, 2021

Criminal Record Clearance: (e) All individuals ...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 observations and record review, the Licensee did not comply with the above regulation with one staff member (S2). LPA Colvin observed that S2 was present in the facility wihtout proof of background clearance. S2 is not associated to the facility. This is an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2021

Plan of correction: Licensee agrees to remove S2 from the schedule until S2 obtains a criminal background clearance and/or has the background clearance transferred to this facility. Licensee to submit proof of S2 being removed from schedule and a Statement of Understanding regarding requirements in Title 22 for all staff to have background clearance AND be associted to the facility prior to starting work/training at the facility. Requested items to be submitted to LPA Colvin by the Plan of Correction date of 10/18/21.