Roxies Elderly Homes I

Allegation investigated: Licensee did not provide planned activities

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to open an investigation regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Licensee Teresita ‘Roxie’ Roxas. During today’s visit, LPA toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed residents and staff. The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee did not provide planned activities. Interviews and LPA observations revealed that residents watch television in the mornings after breakfast and in the afternoon after lunch. The residents will also go outside in the backyard to sit or walk around when the weather permits. Continued on LIC9099-C page... Substantiated Interviews with the Licensee stated that the residents have not been interested in activities and the Licensee tried activities such as bingo, art projects, drawing, writing, and throwing a ball around. The Licensee stated that she does not provide activities to the residents at this time. The Department has investigated the above-mentioned allegation and based on interviews and LPA observations, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Licensee Teresita ‘Roxie’ Roxas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16). Interviews revealed that some residents have personal phones and used them to contact their friends and family independently without staff assistance. Interviews revealed that the other residents were unable to use a phone independently and the Licensee used her personal phone to assist those residents to call or video chat with their families. Interviews revealed that one resident’s personal phone was broken and unable to make phone or video calls, but that resident had not asked to use the facility phone to make any calls. Interviews revealed that the Licensee would offer to call the resident’s family if they asked about them. Interviews did not reveal any instances where the Licensee did not allow residents to use the facility phone. Interviews revealed that the Licensee encouraged residents and their families to bring personal belongings, such as furniture and keepsakes, when moving in. The Licensee stated that she did not encourage families to bring valuables such as jewelry or cash and that the personal belongings could not block passage to the resident’s room. Interviews and LPA observations revealed that residents had personal items in their rooms and in their possession. Interviews did not reveal any instances of the Licensee taking personal belongings away from residents or refusing to allow residents to bring personal items into the facility. Interviews revealed that the residents were encouraged to voice any likes or dislikes to staff and would be provided with options if they did not like the prepared meal. Interviews revealed that some residents preferred to stay in bed later in the morning and staff would accommodate them by assisting residents who were already awake first. Interviews did not reveal any resident concerns or unhappiness with the care provided by the staff at the facility. The Department has investigated the above-mentioned allegations and based on interviews and LPA observations, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Licensee Teresita ‘Roxie’ Roxas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16). Interviews revealed that residents’ responsible parties were provided with the facility phone number. Interviews did not reveal any concerns regarding the facility’s phone number not working. The Department has investigated the above-mentioned allegation and based on interviews and LPA observations, it was determined that the complaint allegation is Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Licensee Teresita ‘Roxie’ Roxas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).the state’s words, verbatim · CDSS document, Jul 11, 2023 · control 08-AS-20230705160601

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Jul 28, 2023

87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement has not been met as evidenced by: Based on interviews and LPA observations, the Licensee did not ensure activities were made available to residents. This poses a potential personal rights risk to 5 of 5 residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2023

Plan of correction: Licensee stated she will speak with the residents to learn what activities they would like and plan activities. Licensee stated she will develop and implement a written monthly calendar with daily activities. The Licensee will submit the calendar to the Department by POC due date.

Allegation investigated: Staff handled resident(s) in a rough manner Licensee did not treat resident(s) with dignity Licensee did not allow visitation at the facility

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Licensee Teresita "Roxie" Roxas. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff handled resident(s) in a rough manner, the Licensee did not treat resident(s) with dignity, and the Licensee did not allow visitation at the facility. Interviews and records review revealed that 5 of 5 residents required assistance with bathing and received showers either daily from facility staff or every other day from outside agencies. Interviews revealed that facility staff assisted residents with showers everyday or provided residents with bed baths on days where residents did not receive showers. Continued on LIC9099-C page... Unsubstantiated Interviews revealed that some residents had instances of not wanting to shower and staff would attempt to redirect residents by talking to them. Interviews did not reveal any concerns regarding staff treating residents roughly during showers. Interviews revealed that staff attempt to accommodate residents’ preferences regarding meal times, types of meals prepared and showering times. Interviews did not reveal any issues or concerns with the staff treating residents without dignity. Interviews and records review revealed that the Licensee set visiting hours for the facility from about 8:00am to 3:00pm. Interviews revealed that the Licensee requested that visitors leave the facility around 3:00pm because there was not enough staff to manage visitation. Interviews and record review revealed that there are two staff scheduled for the AM shift, which is from 6:30am to 12:00pm and one staff scheduled for the PM shift, which is from 12:00pm to 4:00pm. Interviews and records review revealed that the Licensee lived at the facility and was the only staff responsible for care and supervision for residents from 4:00pm to 6:30am every day. Interviews revealed that visitors were able to visit with residents and most residents had daily or weekly visitors. Interviews did not reveal any issues with visitors being unable to visit the facility. Interviews did confirm that the Licensee asked visitors to visit the facility prior to 3:00pm. Interviews revealed that the Licensee stated that she would make exceptions for visitors who were unable to visit prior to 3:00pm, but would still ask that visitors refrain from visiting past 4:00pm. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Licensee Teresita "Roxie" Roxas, 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 25, 2023 · control 08-AS-20230213143754

The state marks this report as 7 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Licensee restrained residents

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to investigate a complaint regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Licensee Teresita "Roxie" Roxas. During today’s visit, LPA toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed residents and the Licensee. The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, LPA observations, and a tour of the facility. It was alleged that the Licensee restrained residents. Interviews revealed that in February 2023, 3 residents were observed to be in barricaded in their beds by chairs, a dresser, and full bed rails with no standing room on any side of the beds. Continued on LIC9099-C page... Substantiated During today's visit, LPA Ruiz observed full bed rails on 3 residents beds. Interviews and records review revealed that 2 of 3 residents are on hospice and 1 hospice resident has an order for full bed rails. Interviews revealed that the residents are placed in their beds and the bed rails are pulled into an upright position for residents between 3pm and 5pm. The Licensee stated that the bed rails remain in the upright position overnight and are lowered in the morning around 7:00am. Interviews revealed that the bed rails, chairs, and furniture are used to alert the Licensee if a resident is getting up while on the overnight shift. Interviews revealed that the full bed rails are used to prevent the residents from falling during the night. The Department has investigated the above-mentioned allegation and based on interviews, record review, and observations, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Licensee Teresita "Roxie" Roxas, 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, Feb 16, 2023 · control 08-AS-20230210112934

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(1) · Plan of correction due date: Feb 16, 2023

87608 Postural Supports (a) Postural supports shall be ... used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including... preventing a resident from falling out of bed, a chair, etc. This requirement has not been met as evidenced by: Based on interviews, records review, and observations, the Licensee did not ensure bed rails were used for mobility. This poses an immedate safety risk to 2 of 3 residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2023

Plan of correction: Licensee removed bedrails for R3 during the LPA's visit. Licensee will attend vendor training for postural supports and submit proof of completion to the Department by POC due date of 3/16/2023.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Miller conducted an unannounced annual required inspection on today's date. LPA was greeted at the front door and granted entry by Teresita Roxas, Licensee, after identifying herself and disclosing the purpose of the visit. An overall tour of the facility was conducted. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other requirements most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. LPA reviewed with Licensee, the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC808) including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility Plans for Infection Control, and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC808. No deficiencies were observed during today's visit. An exit interview was conducted with Licensee, and a copy of this report along with Licensee/Appeal Rights (LIC9058 FAS 01/16) was provided via email; facility representative expressed that they would send LPA a confirmation email upon receipt of these documents.the state’s words, verbatim · CDSS document, Apr 14, 2022