Daybreak Villa West

Type of visit: Case Management - Deficiencies

On 9/27/2023, Licensing Program Analyst (LPA) Janette Romero conducted a case management visit to address a deficiency observed during investigation of complaint control #18-AS-20230922142852. LPA met with Administrator Ronaldo Corpuz who was informed of the purpose of the visit. During LPA's visit at the facility on 9/27/2023, a record review revealed that Staff #1 is not associated to the facility. As a result, LPA assessed a civil penalty. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Corpuz along with a Confidential Names List (LIC811), LIC809-D, LIC421BG and Appeal Rights.the state’s words, verbatim · CDSS document, Sep 27, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(3) · Plan of correction due date: Oct 6, 2023

87355(e) (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r)... This requirement was not met as evidenced by: A record review revealed that Staff #1 present during LPA's visit, is not associated to the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 27, 2023

Plan of correction: Licensee stated the facility will request a transfer of a criminal record exemption for Staff #1 on 9/28/2023. Proof of correction to be submitted to LPA by close of business on 10/6/2023.

Type of visit: POC

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a plan of correction visit. Deficiency were cited on 5/30/2023 during a required annual inspection and 5/31/2023 during an informal office meeting. The LPA met with administrator, Rolando "Bobby" Copruz who was informed of the purpose of the visit. During the visit a health and safety check was conducted on the facility residents. During the time of the visit LPA conducted a walk through of the facility interior and exterior. LPA observed the residents, the food supply, and utilities. The following deficiency was corrected during today's POC visit: Deficiency cited under Title 22 Regulation 87465(h)(2) Incidental Medical and Dental Care. POC to place all medications in a safe and locked area in the facility and send the LPA proof of this by the POC due date 6/6/2023. Deficiency has been cleared as during this visit as the LPA observed medications in locked hallway closet and received photos of this by the POC due date. Clearance letter was given to administrator during the time of the visit. Deficiency cited under Title 22 Regulation 87303(a) Training Requirements If Advertising Dementia Special Care, Programming And/Or Environments . The POC made with the administrator was to hold an in-service with staff and themselves in attendance and send proof of this to the LPA by the POC due date 6/6/2023. The topics shall include: dementia care and fall risk prevention. On today's visit LPA asked for staff training and was show training material staff received and completed. LPA asked staff if they had received fall risk and dementia care training who stated they had received it. LPA received staff sign in sheet by POC due date. Clearance letter was given to administrator during the time of the visit. Deficiency cited under Title 22 Regulation 87456(i) Incidental Medical and Dental Care. The POC made with the administrator was to dispose of the expired medication and submit proof of removal of the medication from the facility along with medication destruction record by the POC due date 6/6/2023. On today's visit LPA observed and took photos of facility built-in fridge which no longer contained expired medication. LPA received copies of medication destruction record by POC due date. Clearance letter was given to administrator during the time of the visit. Deficiency cited under Title 22 Regulation 87303(a) Maintenance and Operation. The POC made with the administrator was to have the built in refrigerator removed, and to submit proof to LPA by the POC due date of 6/6/2023. LPA received proof of this by the POC due date. Clearance letter was given to administrator during the time of the visit. The following deficiencies were not corrected by the POC due date nor at the time of the visit. Civil Penalties are being assessed and will continue to accrue until correction has been submitted: Deficiency cited under Title 22 Regulation 87465(h)(5) Incidental Medical and Dental Care. The POC made with the administrator was to retrain their staff on medication administration and send proof to the LPA of staff in service to discontinue use of weekly pill boxes by the POC due date 6/6/2023. On today's visit LPA spoke with administrator and staff who stated that they had not trained staff on medication administration. During the visit LPA found that the pill boxes had been removed from the facility and been sent photos that pill boxes had been removed. Civil penalties are being assessed for the dates of 6/7/2023 to 6/14/2023 in the amount of $100 per day for 8 days. Civil penalties will continue to accrue at the rate of $100 corrections are made and sent to LPA. Deficiency cited under Title 22 Regulation 87405(a) Administrator- Qualifications and Duties. The POC made with the administrator was to spend 20 hours a week at the facility and to oversee Daybreak Villa East and West and remove themselves as administrator from the other (3) facilities. Proof of removal from facilities as administrator, LIC500 showing the 20 hours allotted per week. This was due by POC date 6/6/2023. On today's visit LPA spoke to administrator who stated they had sent the LPA LIC308 to designate their house managers in their place for other (3) facilities but had not disassociated themselves. POC documented has still not been received. Civil penalties are being assessed for the dates of 6/7/2023 to 6/14/2023 in the amount of $100 per day for 8 days. Civil penalties will continue to accrue at the rate of $100 corrections are made and sent to LPA. An exit interview was conducted with administrator, Rolando Corpuz where this report and civil penalties were reviewed and provided.the state’s words, verbatim · CDSS document, Jun 14, 2023

Type of visit: Office

Licensing Program Analyst (LPA) Janira Arreola conducted an informal office meeting with managing member of Twet LLC, Bin Shen. The meeting was accorded to speak about topics of concern with Daybreak Villa East and Daybreak Villa West (374603760). Provide updated Articles of Incoproration and LIC309 for managing LLC's of the facility: Twet LLC, GODM Investmentsa, Shnaghai Nushi LPA provided consultation to Shen, as they expressed they are looking at a potential buyer for Daybreak Villa West and Daybreak Villa East. Shen was informed of liability of the licensee, and proper notification that is needed to the resident responsible parties and to the department Administration of the facility, and Administrator hours to 20 hours per week at each facility, Daybreak Villa West and Daybreak Villa East Use of restraints on residents in care, Shen agreed would cease immediately and facility would provide the requested documentation by the POC due dates. The facility is to provide the requested Licensee documentation by June 6, 2023 close of business 5 p.m. An exit interview was conduced where this report was reviewed and provided to the Licensee representative, Bin Shen through email for signature.the state’s words, verbatim · CDSS document, Jun 1, 2023

Type of visit: Office

Licensing Program Analyst (LPA) Janira Arreola and Licensing Program Manger (LPM) Joel Esquivel conducted an informal office meeting virtually with Administrator, Roland Corpuz on 5/31/2023 at 9:00 a.m. The meeting was accorded to discuss the following points: Deficiency cited by LPA Arreola on 5/30/2023 concerning Resident #1 (R1) at the facility, and the use of restraints. Fall prevention training for administrator and staff Dementia care training for administrator and staff Unlocked medication observed in facility common areas Removal of inoperable facility refrigerator Proper disposal of expired medications Transferring of medication to other containers Not giving medication as prescribed to (R1) and Resident #2 (R2) Administrator increasing hours present at the facility to 20 hours per week. These items were discussed with the administrator, where they agreed to have the items corrected by June 6,2023 and present corrections to LPA. Citations were recorded on LIC809-D page along with plans of correction. The administrator agreed to contact the licensee, as both the LPA and LPM were unable to gain contact for the informal meeting. The administrator agreed to inform the LPA by June 1, 2023 availability for June 2,2023. An exit interview was conducted where plans of correction for these issues were reviewed and discussed with Administrator, Roland Corpuz. The report was sent to Rolando Corpuz via email for signature.the state’s words, verbatim · CDSS document, May 31, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jun 6, 2023

(h) The following requirements shall apply to medications... (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 requirment was not met as evidenced by: LPA observed unlocked medications that were being kept in (2) facility refrigerators in facility kitchen and living room. This poses an immediate health, saftey or personal rights risk to residents.the state’s words, verbatim · CDSS document, May 31, 2023

Plan of correction: The licensee agreed to place all medications in a safe and locked area in the facility and send the LPA proof of this by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(5) · Plan of correction due date: Jun 6, 2023

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirment was not met as evidenced by: LPA observed all (5) residents had their medication transferred into weekly pill boxes from their original containers. This is an immediate personal rights, health or saftey risk to resident sin care.the state’s words, verbatim · CDSS document, May 31, 2023

Plan of correction: The licensee agreed to retrain their staff on medication administration and send proof to the LPA of staff in service to discontinue use of weekly pill boxes by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465 · Plan of correction due date: Jun 6, 2023

(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirment was not met as ebidenced by: The LPA reviewed medication for R1 and R2 and found that the medication was required everyday per hospice paper work. Staff stated, and MARS logged showed resident was receiving medication as needed. This is an immediate health, saftey or personal rights risks to residents.the state’s words, verbatim · CDSS document, May 31, 2023

Plan of correction: The licensee agreed to retrain staff on the medication administration. Staff in-service will be sent to the LPA by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Jun 6, 2023

(a) ...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours...The Department may require that the administrator devote additional hours in the facility to fulfill his...responsibilities...This requirment was not met as evidenced by: During the informal meeting, the Administrator stated they oversaw (5) facilities and that they were unware fo the extent of the use of the retraints with R1, and medication that was stored unlocked. This poses a potential health, saftey, personal rights risk to residents.the state’s words, verbatim · CDSS document, May 31, 2023

Plan of correction: The administrator agreed to spend 20 hours a week at the facility and to oversee Daybreak Villa East and West and remove themselves as adminsitrator from the other (3) facilities. Proof of removal from facilities as administrator, LIC500 showing the 20 hours alotted per week, and signed statement of understanding of the regualtion cited by the administrator must be submitted by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 6, 2023

(a) The facility shall be...in good repair at all times...provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirment was not met as evidenced by: Based on LPA observation and administrator statements, the facility had a built-in refrigerator which was inoperable in facility kitchen, that was being used to store unlocked medications and documents. This poses a potential health, saftey, or personal rifghts risk to residents in care.the state’s words, verbatim · CDSS document, May 31, 2023

Plan of correction: The adminsitrator agreed to have the built in refrigerator removed, and to submit proof to LPA by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87456(i) · Plan of correction due date: Jun 6, 2023

(i) Prescription medications which are...which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years... This requirment was not met as evidenced by: The LPA observed medication in the facility that was unlocked and expired. This medication had not been disposed of by the facility and poses a potential health, saftey or personla rights risk to resident in care.the state’s words, verbatim · CDSS document, May 31, 2023

Plan of correction: The licensee agreed to dispose of the expired medication and submit proof of removal of the medication from the facility along with medication destrction record by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87707(a) · Plan of correction due date: Jun 6, 2023

(a) Licensees who advertise, promote, or otherwise hold themselves out as providing special care...for residents with dementia...shall ensure that all direct care staff...meet...training requirements This requirment was not met as evidenced by: Based on record review and interview with administrator, the staff at the facility have not received dementia care training as outlined in the facility's dementia care plan. This poses a potential personal, health or safety risk.the state’s words, verbatim · CDSS document, May 31, 2023

Plan of correction: The licensee agreed to hold an inservice with staff and themselves in attendance and send proof of this to the LPA by the POC due date. The topics shall include: dementia care and fall risk prevention.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/30/2023 at 02:15 p.m. LPA was granted entry and met with staff, Betty Mangiliman who was informed of the purpose of the visit. LPA spoke with Administrator Rolando Corpuz over the phone. At the time of the visit there was (3) staff and (5) residents present. The facility is a one story home with (6) bedrooms and (3) bathrooms with attached garage. No pools or firearms are being kept at the facility. The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and client interviews. LPA observed and cited the following: The facility staff and administrator along with LPA observation, found that Resident # (R1) was being held in their bed against their will. Deficiencies and observations and interviews were documented and will be discussed with the administrator during an informal office visit. The administrator agreed to meet the LPA and their manager on 5/31/2023. An exit interview was conducted where this report along with deficiency page and appeal rights were reviewed and provided to the staff, Betty Mangilisman.the state’s words, verbatim · CDSS document, May 30, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met with Caregiver Remedios Semon and explained the purpose of today's visit. Semon phoned Administrator Bobby Corpuz and notified him of LPA's presence and he arrived shortly thereafter. Four (4) of five (5) residents were present during LPA's visit. During the inspection, LPA interviewed Corpuz regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings in the facility which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 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 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, 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. No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 26, 2022