Lilac Chateau 1

Type of visit: Collateral

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced collateral visit to the facility to obtain records and conduct staff interviews. LPA Lopez identified herself and was granted entry by Victoria Sumalinog, caregiver. Staff Jovy Fronda, caregiver was also present at the facility. LPA stated the purpose of the visit with Kimberly Withers, Licensee. During the visit, LPA Lopez interviewed staff #1 (S1), and Staff #2 (S2), and requested relevant documents. No deficiencies were observed during today's visit. An exit interview was conducted, and a copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) were provided to Victoria Sumalinog, caregiver, at the conclusion of the visit. The signature below confirms the receipt of the documents.the state’s words, verbatim · CDSS document, Jun 9, 2023

Allegation investigated: Facility did not refund the balance of rent upon resident death.

Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA was allowed entry into the facility after identifying herself and stating the purpose of the visit to Caregiver, Victoria Sumalinog. LPA met with Licensee, Kimberly Withers The Department’s investigation consisted of a review of facility administrative and care records. It also involved interviews with facility staff, and outside sources. The Department received a complaint on September 13, 2021, alleging that the facility did not issue a refund of the balance of rent upon a resident death. Interviews with the Licensee and with outside sources revealed that resident 1 (R1) was a resident at the facility and their legally responsible person signed an admission agreement on August 30, 2021. At the time of admission, R1 was receiving palliative care services. [CONTINUED ON LIC 9099-C, 1 of 3] Substantiated On September 5, 2021, R1 began hospice services. On September 8, 2021, R1 passed away. R1’s responsible party had paid the facility $7,000 for care of R1 for the month of September 2021. On September 9, 2021, R1’s responsible party removed R1’s belongings from the facility. At this time, R1’s responsible party inquired about receiving a refund. Staff at the facility told the responsible party that the Licensee would need to be contacted regarding any refunds. Interviews and review of facility records revealed that the facility has a policy of not providing refunds to any residents that receive hospice or palliative care services. Facility records reviewed revealed that there is an admission agreement addendum that states “In the event that a resident is admitted to palliative care or hospice, the basic monthly fee and admission deposit, if any is non- refundable. This is due to extra expenses of PPE and extra expenses of such care”. Facility records reviewed indicate that R1’s responsible party had signed an addendum stating the former. Interviews with the licensee revealed that although there is a no refund policy addendum as part of the admissions agreement, she uses her discretion as to when this policy is implemented and will work with families if they have an issue with the policy. The Department notified the Licensee of the complaint on September 21, 2021. On September 24, 2021, R1’s responsible party was provided a refund of more than $4,000. Interviews with staff and outside sources corroborate that a refund was given. The refund of the balance of rent paid in September 2021 was provided to R1’s responsible party within required 15 days of R1’s belongings being removed from the facility. (CONTINUED ON LIC 9099-C, 2 of 3) During the course of the Department’s investigation, records revealed that there were at least two additional former residents’ responsible parties that did not receive a refund for the balance of rent after the residents passed when the residents were receiving hospice services. Interviews with these former residents’ responsible parties revealed that they did not realize that they could potentially have a refund, so they never inquired. Resident 2 (R2) was admitted into the facility on October 29, 2015. R2 began hospice services on August 16, 2021 and passed away on September 3, 2021. R2 had prepaid the facility approximately $ 5,000 for the month of September 2021 prior to them passing. R2’s responsible party removed R2’s belongings from the facility approximately a week after R2’s death. Unlike R1, R2 and/or their responsible party had not signed the addendum to the admission agreement. Resident 3 (R3) was admitted to the facility on October 17, 2016. R3 began hospice services on May 27, 2021 and passed away on June 6, 2021. R3 has a signed addendum to the admission agreement in their file that stated they would not receive a refund. R3’s responsible party stated that R3’s belongings were removed from the facility within a few days of their passing. R3’s responsible party had prepaid the facility approximately $ 5,000 for care of R3 in June 2021. A review of the addendum revealed the Department had not approved the change to the Admission Agreement and it was determined to not meet the Health and Safety Code. Based on interviews, and reviewed records, a preponderance of evidence exists to substantiate the allegation. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly created with the licensee. An exit interview was completed with the licensee, to whom a copy of this report, LIC 811 (Confidential Names List) and the Licensee/Appeal Rights (LIC9058 01/16) were provided via e-mail.the state’s words, verbatim · CDSS document, Nov 15, 2021 · control 08-AS-20210913142247

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Nov 9, 2021

1569.652 (c) Termination of admission agreement upon death of resident; removal of resident’s property, refund of fees paid; notice of contract termination and refunds. A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual,...or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement was not met by; Based on interviews and records review, the licensee did not refund any fees paid in advance covering the time after the resident’s personal property had been removed from the facility for 2 of 6 persons in care, which posed a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 15, 2021

Plan of correction: Licensee will refund the balance of rent due to R2 and R3'S estate or responsible party. Licensee will refund the amount due on or before December 6, 2021. Licensee will provide documentation to LPA of payment on or before December 6, 2021. Licensee will remove unlawful addendum to the admission agreement, will notify all current residents of unlawful addendum, and provide updated admission agreement to LPA on or before December 20, 2021

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Kristina Ryan conducted a case management visit to cite for a deficiency observed while completing a records review for a complaint. LPA met with Licensee, Kimberly Withers, and discussed the purpose of the visit. While reviewing records for a complaint, LPA found that Resident 1 (R1) was admitted and retained with a diagnosis and symptoms of a contagious infection. Interviews with facility staff revealed that the staff were aware that (R1) had a history of this infection, and symptoms of the infection began the same day that R1 moved in. A deficiency is being cited pursuant to Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D. An exit interview was conducted, and this report was discussed with the licensee. A copy of the report, LIC 809-D, and Licensee/Appeal Rights (LIC 9058 01/16) will be emailed to the licensee following the visit. Acknowledgement of receipt of the documents is requested upon receiptthe state’s words, verbatim · CDSS document, Nov 15, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87615(a)(4) · Plan of correction due date: Nov 9, 2021

87615 Prohibited Health Conditions (a) (4) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Staphylococcus aureus ("staph") infection or other serious infection. This requirement was not met as evidenced by; Based on record review and interviews, the licensee did not ensure, that one out of four residents, did not have a prohibited health condition. This posed a potential Health risk to persons in care.the state’s words, verbatim · CDSS document, Nov 15, 2021

Plan of correction: Licensee will review 87209- Program Flexibility and will provide training to staff on prohibited health conditions and exception request documentation. Licensee will submit training topics and staff sign in sheet to LPA by December 10, 2021.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Correia visited the facility to conduct an annual required licensing inspection. LPA identified herself, was granted entry into the facility and met with Licensee Kimberly Withers, with whom she discussed the purpose of the visit. During today's visit, LPA toured the facility to verify compliance with infection control practices. LPA and facility staff reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation. LPA observed one central entry point for universal entry screening; including temperature and symptoms checks, a questionnaire regarding possible exposure, and vaccination and/or test result checks for staff, residents and visitors. Signs in the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; hand sanitizer/hand washing stations readily available; available visitation areas; emergency agencies’ and emergency contact information are all up to date and readily available. LPA observed an adequate supply of cleaning products and PPE supplies at the facility. No deficiencies were cited during today’s visit. An exit interview was conducted with Licensee Withers, and a copy of this report and Licensee Rights (LIC 9058, FAS 01/16) were provided to Licensee Withers via email following the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.the state’s words, verbatim · CDSS document, Nov 10, 2021