Cedars @ Paradise Village

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Amy Rodgers and Juliana Barfield, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPAs Rodgers and Barfield were granted entry into the facility by Exevcutive Director, Nicole Long, after identifying themselves and stating the purpose of the inspection. The facility serves one hundred fifty (150) non-ambulatory elderly residents age sixty (60) and above; of which six (6) may be bedridden and may use designated rooms. There is an approved hospice waiver for six (6). This is a four-story complex, with marked entry and exit door on first floor. Elevators are available for residents to use to access all floors. LPA was accompanied by the Executive Director, Nicole Long during a tour of the facility. Tour was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. The last disaster drill was conducted in October 2023. PPE supplies are onsite. No bodies of water are on premises. Passageways were free from obstructions. According to Executive Director, Nicole Long, there are no weapons and/or ammunition stored on the premises. All doors were operational. Each resident had clean and sufficient bed linens. All extra linens, towels, and washcloths are all accessible in rooms or in locked hall closet. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. There is an emergency supply of drinking water. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room. Medications were labeled, as required, and stored in locked areas. Staff records review verified that all staff records are complete and compliant. All direct care staff have First Aid certificates and First Aide/CPR certificates, and staff training .Resident records reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a thorough review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. An exit interview was conducted, this report was discussed with Executive Director, Nicole Long. The report along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to the by Executive Director, Nicole Long.the state’s words, verbatim · CDSS document, Oct 30, 2023

Allegation investigated: Facility does not have sufficient staff to meet the needs of the residents. Unqualified staff are providing care to residents. Due to lack of sufficient staff, residents are made to wait an excessive amount of time for assistance, Staff does not maintain facility clean and sanitary. Facility staff does not maintain residents' rooms free of odors. Facility staff are not meeting residents' laundering needs. Facility staff are not providing residents food and water at night. Facility staff are not accurately maintaining residents' records.

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry by Katrina Jimenez, Resident Services Director. LPA identified herself and disclosed the purpose of the visit and elements of the findings with the Resident Services Director. The Department investigated the above complaint allegations. The investigation consisted of a tour of the facility, interview with staff, residents, and records review. On January 4, 2023 a complaint was received alleging several accounts of negligence and inadequate staffing at Cedars @ Paradise Village. The complainant stated that the facility does not have sufficient staff to meet the needs of the residents, resulting in unqualified staff providing care. Additionally, residents are made to wait an excessive amount of time for assistance due to the lack of sufficient staff. Unsubstantiated The complainant further noted that the facility is not maintained clean and sanitary, with several reports of foul odors in the residents' rooms. Furthermore, it was reported that the facility staff is not meeting the residents' laundering needs and is not providing them with food and water at night. During the investigation, it was observed that the facility sufficient number of staff members available, which did not affect their ability to provide adequate care to the residents used the registry for additional staffing needs. The staff-to-resident ratio is 22:1 depending on census. Interviews conducted with staff members revealed that there were not any instances where unqualified individuals were assigned to provide care to residents. An onsite inspection of the facility did not confirmed the complaints about the lack of cleanliness. Several areas, including residents' rooms, bathrooms, and common areas, were found to be adequately maintained, with no visible dirt, dust, and odors present. Residents laundering needs are done once a week, with beds made daily. Moreover, residents have refrigerators in their rooms and snacks are provided on the second floor of the facility as well as in the kitchen after hours. Resident can also leave the facility and bring food in. Residents' records did not indicate any discrepancies or inaccuracies in documentation, suggesting a lack of attention and diligence on the part of facility staff. Furthermore, training's for staff are done online and on a monthly basis. Response time on average is between 15-20 minutes for staff to respond to pendent calls. There were no reported instances where facility staff removed and hid resident's emergency call pendants, limiting their ability to seek help when needed. There was insufficient evidence found to support the allegations that Facility does not have sufficient staff to meet the needs of the residents; Unqualified staff are providing care to residents; Due to lack of sufficient staff, residents are made to wait an excessive amount of time for assistance; Staff does not maintain facility clean and sanitary; Facility staff does not maintain residents' rooms free of odors; Facility staff are not meeting residents' laundering needs; Facility staff are not providing residents food and water at night; Facility staff are not accurately maintaining residents' records; Facility staff are not adequately trained; Facility staff removes and hides residents' pendants; Facility staff does not ensure that residents are adequately fed; Facility staff did not serve appropriate food for resident resulting in resident choking; Due to a lack of evidence, the allegations are deemed to be Unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Katrina Jimenez, Resident Services Director. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Resident Services Director and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Sep 26, 2023 · control 08-AS-20230104140228

Allegation investigated: Facility staff did not treat resident with dignity

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow-up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Senior Executive Director Bill Lawson. LPA also met with Resident Care Coordinator Sheryll Chicano. During today's visit, LPA toured the facility and interviewed staff and residents. The Department’s investigation consisted of interviews with residents and staff, records review, and a tour of the facility. It was alleged that facility staff did not treat resident with dignity. Interviews revealed that Resident 1 (R1) required assistance with bathing. In June 2020, Staff 1 (S1) assisted R1 during a shower and R1 believed that S1 had unintentionally treated them roughly. Continued on LIC9099-C page... Unsubstantiated Interviews revealed that R1 had a medical condition and a recent medical procedure which caused R1 to have a sore and stiff arm. Interviews revealed that R1 did not inform S1 of R1’s sore arm and did not ask S1 to be gentler when showering R1. Interviews with staff and residents did not support any evidence or concerns of rough treatment of residents during showers. The Department was unable to interview S1. The Department has investigated the above-mentioned allegation and based on interviews, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Senior Executive Director Bill Lawson, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.the state’s words, verbatim · CDSS document, Apr 3, 2023 · control 08-AS-20200618160126

Allegation investigated: Facility is not following Covid 19 infection control requirements Facility is not following Covid 19 reporting requirements

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings to the above mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Administrator Nicole Long. The Department’s investigation consisted of client and outside sources records review, interviews with staff and outside sources. It was alleged that the facility was not following COVID-19 infection control and reporting requirements. Resident #1 (R1) tested positive for COVID-19 while at the hospital. Upon R1’s return to the facility an outside source #1 (OS1) reported that the facility did not inform the staff, visitors and other residents of R1’s newly diagnosed positive COVID-19 test result. (Continue on LIC9099C) Unsubstantiated Review of facility records revealed that the facility was following infection control requirements in regards to R1’s positive status. LPA observed personal protective equipment (PPE) being used by staff, residents and visitors. The facility continued weekly testing and screening for COVID-19 symptoms. Based on interviews with staff, residents and visitors, they were made aware of what rooms and areas that were under isolation. Review of facility records revealed that the staff was trained on infection control requirements with outside vendors. Facility documents and outside source documents revealed that the facility was reporting new cases of COVID-19 and following the facilities mitigation plan. Interviews with staff revealed that they were made aware of the residents that were diagnosed with COVID-19. The Department received documentation of staff and residents that tested positive for COVID-19. The facility also has an approved COVID-19 mitigation plan and infection control plan. Based on records reviewed, staff interviews and outside sources interviewed, there is not a preponderance of evidence that the facility was not following Covid 19 infection control requirements and reporting requirements. Therefore, the allegations are unsubstantiated. An exit interview was conducted with the Administrator and a copy of this report, and Licensee Appeal Rights (9058 03/22) were provided to the Administrator whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 22, 2023 · control 08-AS-20220928104114

Allegation investigated: Licensee employed a staff lacking criminal record clearance.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by and identified himself to Receptionist Ashley Farfan-Garcia. LPA then met with and discussed the purpose of the visit with Executive Director Nicole Long. It was alleged licensee employed Staff #1 (S1) at the facility, despite S1 lacking the required criminal record clearance to work there. The Department’s investigation involved an unannounced facility tour, interviews of relevant staff, and a review of S1’s personnel file and CCLD’s Licensing Information System (LIS) database. [CONTINUED ON LIC 9099-C] Unfounded [CONTINUED FROM LIC 9099] In their required LIC508 Criminal Record Statement, dated 06-24-2022, S1 wrote they had no criminal history. According to facility records and interviews with 2 of 2 managers, S1 underwent the Live Scan fingerprint process, then successfully obtained a criminal record clearance on 07-18-2022. This is corroborated by review of official correspondence from both the California Department of Social Services (CDSS) and the California Department of Justice (DOJ) sent to the licensee. S1 was subsequently hired by licensee on 07-25-2022 and began working. In connection with this complaint, LPA reviewed the LIS database on 09-02-2022. LPA confirmed that even as of that date, S1 had an “Active – Working” status, with no criminal history on file, and no administrative actions against them. S1 had a valid criminal record clearance and was also correctly associated to the facility’s roster. Based on records and interviews, the allegation that licensee employed S1 without a valid criminal record clearance is unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the allegation. An exit interview was conducted with Long, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided. [CONTINUED FROM LIC 9099] CCLD’s investigation consisted of three unannounced facility visits, interviews of relevant staff, and review of the facility’s infection control policies and training sheets, vaccination records, laboratory testing results, and contractor invoices. The Department also revisited its own database of previous COVID-19 reported cases and notes from past phone calls with the administrator on infection control. Staff interviews and CCLD’s collected data revealed Staff #1 (S1) was the first COVID-19 positive person within the specific outbreak that is the subject of this complaint. S1 last worked at the facility on 08-21-2022, developed symptoms on 08-22-2022, and was COVID tested on 08-23-2022, with a positive result. A facility manager said S1 was interviewed as part of a CDSS-endorsed process called “contact tracing”; it revealed S1 “worked only on the facility’s 3rd floor in the 72 hours before [S1] became COVID-19 positive.” CDSS Provider Information Notice (PIN) 22-16-ASC was the testing guidance in force during the timeframe of the allegation. According to this PIN, in facilities where more than 90% of both residents and staff were fully “fully vaccinated,” and where contact tracing was feasible, licensees were authorized to limit their weekly response testing to the those who had “close contact” with the infected person, rather than response testing all staff and all residents at large. According to facility records, around 98% of its staff and 93% of its residents were “fully vaccinated” when S1 became COVID-19 positive. Consistent with PIN guidance, licensee waited 48 hours to overcome the virus’ incubation period. Then on 08-24-2022, licensee response tested 21 residents who lived on the facility’s 3rd floor plus two staff who had contact with S1; all results returned negative. On 08-29-2022, licensee tested R1 individually, since they developed new COVID-19 symptoms; the result was positive. Licensee immediately tested R1’s spouse/roommate, Resident #2 (R2), but R2 remained asymptomatic and COVID-negative. Leveraging a nurse-staffing contractor, licensee performed its second-week response testing on 08-31-2022, expanding the sweep to 100 persons tested (going beyond “close contacts”). This time, R2 and Staff #2 (S2) were COVID-positive. On 09-07-2022, licensee used the same nurse-staffing contractor to execute a third week of response testing involving 112 persons (again going beyond “close contacts”). There were no new positive cases, and this remained true even during the next week’s response testing, effectively ending the COVID-19 outbreak. The above chronology of licensee’s response testing was corroborated by laboratory results, contractor invoices, and CDSS records. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] According to PIN 22-15-ASC and the California Department of Public Health order in force during the timeframe of the complaint, all facility staff were required to wear surgical facemasks when working with residents. The facility’s own internal written policy on facemasks reiterated this point and required all staff to obtain a new/clean surgical mask at the start of each shift from the facility’s lobby front desk. LPA interviewed 4 receptionists who are primarily stationed at the facility’s front desk. Each said they themselves wear a surgical mask for the duration of their shift, and that coworkers from all other job positions consistently don a surgical mask before working with residents. These observations were echoed in interviews of 2 of 2 managers. LPA visited the facility twice unannounced during late August 2022, which is the timeframe of the complaint allegation, and once unannounced in early September 2022. LPA interacted with administrative staff, culinary staff, maintenance staff, caregivers, nurses, and medication technicians. Every employee encountered was wearing a surgical mask securely over their nose and mouth. Licensee previously filed an Infection Control Plan with CCLD and trained its staff on it. According to this plan, and consistent with regulation, used/soiled gloves must be discarded “in nearest appropriate waste receptacle with a tight fitting cover” after each task. LPA interviewed 4 receptionists and 1 manager whose workstations are very close to the two trash cans which the complainant referenced. All said they have not seen any soiled gloves on the floor either beside these trash cans or in other common areas of the facility. During LPA’s three unannounced visits, which included a tour of the facility’s medication room and walking through multiple hallways on every floor, LPA did not encounter any used/soiled gloves on the floor. Based on interviews, record reviews, and LPA observations: A preponderance of evidence does not exist to prove that licensee fell short of COVID-19 response-testing requirements, or that facility staff did not wear their required surgical masks, or that facility staff left used/soiled gloves on the floor. The three allegations are therefore unsubstantiated. An exit interview was conducted with Long, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Oct 17, 2022 · control 08-AS-20220831124847

Allegation investigated: Licensee did not give resident medication(s) as prescribed.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Nicole Long and Resident Service Director Katrina Jimenez. It was alleged that licensee assisted Resident #1 (R1) with their normally prescribed medications, but between July 27, 2022 and July 29, 2022, two specific medications were handed to R1 in amounts less than what was specified/required by their signed physician’s order (an order which was received and acknowledged by licensee' staff on the date it was to take effect). [See attached LIC811 Confidential Names List for a description of person identifiers used in this report]. CCLD’s investigation involved interviews of pertinent residents, facility staff, and outside sources. The Department also reviewed administrative, care, and medication records from R1’s file, plus relevant E-mails and phone text message(s). [CONTINUED ON LIC 9099-C, 1 of 2] Substantiated [CONTINUED FROM LIC 9099] According to interviews and facility records, R1 was diagnosed with Mild Cognitive Impairment and relied on facility staff for assistance with taking their prescribed medications. During the timeframe of the complaint allegation, R1 often attended an outpatient clinic twice per week. Based on R1’s blood tests, it was common for two specific medications to be adjusted/changed following clinic visits. On July 27, 2022, R1’s clinic physician determined that both of the said medications must now be given to R1 twice per day (instead of once per day). According to interviews of multiple outside sources, clinic staff faxed a signed valid order to the facility's nursing office, then phoned a supervisor there to confirm receipt and understanding. According to interview of Facility Supervisor #1 (S1), they received this faxed order on July 27, 2022, and told clinic staff that their team would implement the medication changes for R1 that same day. [Licensee thus had timely constructive knowledge of the orders]. According to interview of Facility Supervisor #2 (S2), they too saw the faxed order on July 27, 2022, as did S1. S1 and S2’s timely receipt was further corroborated in a phone text message between them about this specific order (the text message was date-stamped July 27, 2022). Staff interviews revealed that this faxed order was then placed a designated basket inside the facility’s nursing office, to be entered/transcribed into the facility’s medication management software. Ultimately, however, the order was not entered into the software as was expected (rather, it was subsequently misfiled elsewhere), a fact corroborated by S1, S2, and nursing department Staff #3 (S3). R1 thus received only half of the required dosage for two of their medications for three days; the errors which were discovered when R1 returned to the outpatient clinic on July 29, 2022. These facts were corroborated in follow-up E-mails that clinic staff sent to S1. [All parties, including R1 themselves, confirmed R1 suffered no adverse health event or injury due to said error(s)]. Clinic staff immediately contacted S1 by phone and fax to correct the errors. S1 told LPA they acknowledged a mistake had occurred and apologized to the clinic staff. By July 30, 2022, facility staff had resumed giving R1 both medications according to correct/prescribed amounts. Prior to CCLD receiving the complaint, S1 independently implemented a new routing procedure within the facility’s nursing office, with the goal of preventing future medications orders being overlooked. Aside from S1, LPA interviewed three other facility staff who distribute medications; all three consistently described the new office procedure that S1 established. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Based on interviews and records, the preponderance of evidence shows that on at least a few days, licensee did not give R1 two of their medications according to how they were prescribed. Licensee’s staff quick took action to correct and learn from the mistake, and were cooperative and forthcoming during CCLD’s investigation. The allegation, however, is substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Long and Jimenez, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Aug 31, 2022 · control 08-AS-20220816115653

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 30, 2022

87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist resident with self-administered medications as needed.” This requirement was not met, as evidenced by: Based on records and interviews, R1 relied on licensee for help with medications, but licensee’s staff did not hand R1 the correct/prescribed amounts for two of their medications. This posed a potential health risk to 1 of 92 residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2022

Plan of correction: The Executive Director (ED) and Resident Service Director (RSD) both said that all medication orders which are entered into software (PCC) are now double verified by another nursing department staff, at least weekly. ED agreed to require: a) once per month, the RSD or the Resident Service Coordinator (RSC) will randomly select 3 medication orders and compare them against PCC, b) the auditor will immediately notify the ED of any transcription errors, and c) for any actual medication errors (in practice), they will also notify the resident’s physician and responsible party and submit an LIC624 Incident Report to CCLD. The ED agreed to codify the above in a written internal memorandum, which will indicate the new procedures’ effective date and be signed by the ED, RSD, RSC. ED agreed to E-mail a copy of the signed memorandum to LPA by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Nicole Long. LPA conducted a brief tour of the facility and observed the staff and residents in care. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, screening protocols, and the use of personal protective equipment. No deficiencies were cited on this date. An exit interview was conducted with Long, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Aug 23, 2022

Allegation investigated: Staff Financially abused resident

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint investigation visit at the facility. LPA was greeted at the front entrance by Staff Priscilla Oseguera, and granted entry after identifying herself. LPA met with Administrator, Nithi Narasappa and explained the purpose of the visit was to deliver findings for the above allegation. The Department’s investigation consisted of multiple interviews with facility staff, outside sources and records review, including bank statements, law enforcement reports and other relevant documents pertinent to this investigation. On March 22, 2022, a complaint was filed with Community Care Licensing with the allegation involving financial abuse of a resident by staff member. It was reported that Staff (S1) financially abused Resident (R1) by altering a $100 check draft issued on February 13, 2022, to S1. Administrator was provided with Confidential Names Form (LIC 811) in order to identify R1 and S1. It was alleged that S1 financially abused R1 by adding zero to the amount in the line field increasing the value from $100 to $1,000. Continued 9099C Substantiated Continued from LIC9099 Per Administrator, on March 17, 2022, when R1 notified her of the alleged forgery, she immediately notified law enforcement and completed all reporting requirements to licensing and Long-Term Care Ombudsman. Administrator, Narasappa indicated that their company new hire onboarding process requires for all staff to complete trainings that specifically include a comprehensive review of personnel policies and procedures. The company personnel handbook states that it is against company policy for any employee to accept money or gifts from a resident, a family member or any other facility affiliate. In addition, Narasappa stated that S1’s position provides direct resident care to residents by bringing them meals, therefore S1 received specific trainings as a caregiver and mandated reporter requirements. LPA reviewed onboarding documents and training records and confirmed the onboarding process was completed and acknowledged by S1, which disclosed no exceptions in the hiring process. In addition, facility received background clearance for S1 prior to hiring on March 2, 2020, which indicated no prior criminal activity. Review of the Facility Resident Theft and Loss Record (LIC9060) disclosed no other loss or stolen personal property. Based on review of hiring practices, training practices and internal control systems established at the facility it appeared that this was an isolated incident that only affected R1. On April 8, 2022, S1’s employment was terminated and subsequently S1 was arrested and charged with two (2) felony charges, Penal Code 470 (D) forgery and Penal Code 368 (E) financial elder abuse by caretaker. The criminal case is pending. Based on interviews conducted and records review there is sufficient evidence to support the allegation. The investigation findings clearly indicated that the intended amount of the check of $100 written by R1 was subsequently changed by S1 to $1,000 without R1’s knowledge nor approval. Review of security surveillance video by law enforcement confirmed S1 as the individual depositing the check issued by R1. Therefore, the allegation is deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A plan of corrections was developed with Administrator, Narasappa and was subsequently completed on April 13, 2022. An exit interview was conducted with Administrator, Nithi Narasappa and a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) were provided.the state’s words, verbatim · CDSS document, Apr 27, 2022 · control 08-AS-20220322144630

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 29, 2022

Personnel Requirements - General Facility personnel shall at all times be competent to provide the services necessary to meet resident’s needs. This requirement was not met as evidenced by: Based on interviews and record review, licensee did not ensure personnel were competent, as Staff (S1) financially abused 1 of 98 residents in care. This posed a potential personal rights risk to 1 of 98 residents in carethe state’s words, verbatim · CDSS document, Apr 27, 2022

Plan of correction: On April 13, 2022, Administrator conducted a facility wide in service training with all staff on company personnel policy including the prohibition of employee to accept money or gifts from a resident or family members. In addition, in service trainings were provided to all staff on mandated reporter requirements. Tranining records will be updated on staff personnel files. POC has been completeted.

Type of visit: Case Management - COVID-19

Licensing Program Analyst (LPA) Marisela Garcia-Centeno, and County of San Diego Senior Public Health Nurses, Robert Montillano and Jennifer West, conducted an in-person visit. All staff present at the facility had a current criminal record clearance. LPA and Nurse Montillano and West identified themselves and discussed the purpose of the visit with Administrator, Nithi Narasappa. The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's disinfection and screening protocols. During today's visit, the team interviewed the Administrator and provided consultation and conducted a walk-though of the facility. A debriefing was conducted with the Administrator at the conclusion of the visit. During today's visit, no deficiencies were issued. An exit interview was conducted with Administrator, Narasappa, and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.the state’s words, verbatim · CDSS document, Jan 11, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Marisela Garcia-Centeno conducted an unannounced Required 1 - Year Visit. LPA was allowed entrance by Staff Member, Jeanne Reis. The facility file was reviewed prior to the visit. LPA met with Resident Services Director, Katrina Esguerra and Administrator, Nithi Narasappa, and we discussed the purpose of the visit. All staff present have a current criminal record clearance. LPA conducted a tour of the facility, both inside and outside and observed the clients in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment. No deficiencies were cited or observed on this date. The Licensee was provided a copy of her appeal rights (LIC9058 01/16). An exit interview was conducted with Resident Services Director, Katrina Esquerra and a copy of this report was emailed to the Administrator, Nithi Narasappa with an electronic read receipt as confirmation of documents.the state’s words, verbatim · CDSS document, Oct 19, 2021

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marisela Garcia-Centeno made a Case Management visit to follow-up on a resident's death. LPA was granted entry into the facility by Receptionist, Carlene Basallo. LPA spoke with Resident Services Director, Katrina Esguerra, to whom she disclosed the purpose of the visit. A Incident Report was received by Community Care Licensing (CCL) on September 18, 2021, informing that Resident #1 (R1) [staff was provided an LIC 811 that identifies the client] passed away at Resident's private home on September 13, 2021. According to information provided to CCL, R1's responsible party informed the Administrator of R1's death on September 13, 2021. During today's visit, LPA reviewed and obtained copies of R1 and facility records and conducted a staff interview. No deficiencies were cited during today’s visit. The Licensee was provided a copy of the appeal rights (LIC9058 01/16). An exit interview was conducted, and a copy of this report was emailed to Resident Services Director, Katrina Esguerra with an electronic read receipt as confirmation of receipt of documents.the state’s words, verbatim · CDSS document, Sep 21, 2021

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Case Management Visit. LPA met with Administrator, Nithi Narasappa, and discussed the purpose of the visit. All staff that interacted with LPA had a current criminal record clearance. Today's visit is in response to the self-reported incident regarding Resident 1 (R1 - see LIC811 Confidential Names List), that was submitted to the Regional Office on August 11, 2021. LPA conducted a health and safety check at the facility, and no health or safety issues were identified. All staff present that interacted with the LPA have a current criminal record clearance. Residents observed appeared appropriate for the facility. Facility records were obtained on this date. No deficiencies were cited or observed on this date. An exit interview was conducted and a copy of their appeal rights (LIC9058 01/16) along with a copy of this report was provided to Administrator, Narasappa via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.the state’s words, verbatim · CDSS document, Aug 16, 2021