Las Villas Del Norte

On 2/25/2025, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to deliver amended findings for the allegation listed above. LPA met with Administrator, Jolene Farish who was informed of the purpose of the visit. It was alleged the facility may have unsanitary food practices and servers did not wash their hands on 1/2/2025, due to a resident’s visitor falling ill after having a meal provided by the facility. LPA toured the facility, conducted interviews, and reviewed records. During tour of the kitchen, LPA observed the freezer was maintained at a temperature of 0 degrees Fahrenheit (F) and refrigerator at 31 degrees F. LPA also observed kitchen staff wearing gloves while preparing food. LPA observed perishable and non-perishable food stored in a safe manner. LPA toured the memory care bistro and did not observe any issues or concerns regarding food safety requirements. *This is an amended version of the original report. UnsubstantiatedRead the full finding— CDSS inspection report, January 10, 2025 · control 18-AS-20250108152134

Licensing Program Analyst (LPA), Amy Rodgers conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA was greeted at the front lobby by Executive Director, Jolene Farish and was granted entry after identifying herself and disclosing the purpose of the visit, which was to further invistagate a complaint. During the invistagation the facility was toured, records reviewed, and interviews conducted with staff and outside sources. (continued on 9099-C) Substantiated— CDSS inspection report, December 12, 2024 · control 08-AS-20210628125732

On 10/21/2024, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to the facility to investigate the allegations listed above. LPA met with Administrator, Jolene Farish who was informed of the purpose of the visit. It was alleged a resident arrives to the dining room at 11:30 a.m. and their food is not served until 1:00 p.m. It was also alleged the resident walked away from the dining room with no food due to the long wait time(s). It was further alleged Staff 1 (S1) and Staff 2 (S2) yell at the resident and are rude to them. The alleged victim's name was not disclosed; therefore, LPA interviewed a sample of five (5) residents. Culinary Service Director (CSD), George "Lynn" Sharp was also interviewed and reported the facility offers a daily menu where breakfast is scheduled to be served at 8:00 a.m., lunch at 12:00 p.m and dinner at 5:00 p.m. CSD also reported the facility offers an alternative menu with options available from 8:00 a.m. to 6:30 p.m. UnsubstantiatRead the full finding— CDSS inspection report, October 21, 2024 · control 18-AS-20241015095756

On 8/20/2024, Licensing Program Analysts (LPAs) Janette Romero and Debbie Palacios arrived unannounced to deliver findings regarding the above complaint. LPAs met with Administrator, Jolene Farish and Resident Care Director (RCD), Ana Ramirez who were informed of the purpose of the visit. On 7/23/2024, it was alleged there is no housekeeping staff to clean the Memory Care Unit (MCU). On 7/31/2024, LPA Romero toured the facility, conducted interviews, and obtained copies of pertinent documentation. LPA Romero toured nine (9) resident bedrooms and bathrooms with Regional Director (RD), Nathan Condie and RCD Ramirez and observed six (6) of nine (9) resident bathrooms appeared to have feces stuck inside the toilet bowls, on the toilet seats, on the bathroom floor, and/or on the outside bedroom door handles. Three (3) of nine (9) resident bedrooms and bathrooms toured appeared to be in sanitary condition. LPA also observed feces on the floor in the shower near room 311. SubstantiatedRead the full finding— CDSS inspection report, August 20, 2024 · control 18-AS-20240723150513

Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Executive Director, Jolene M. Farish, where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and records review. On 06/19/2024, Community Care Licensing received a complaint alleging facility does not ensure that the residents are provided with hot water while in care and the facility does not ensure that the facility is clean or sanitized. It was reported that the facility did not have hot water and shower the residents with cold water. LPA sampled 5 random resident’s rooms’ water temperature and all areas met regulation’s standards. Information obtained from an interview with Executive Director stated the facility has hot and cold water and there were no maintenance issues that would give theRead the full finding— CDSS inspection report, July 15, 2024 · control 18-AS-20240619164822

On 1/4/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced complaint visit to deliver amended findings regarding the allegation listed above. LPA met with Administrator Jolene Farish. Regarding the allegation of “Staff overcharged resident for care” it was alleged that Resident 1 (R1) was over charged for monthly care fees after the resident was absent from the facility for over fourteen days due to hospitalization. LPA reviewed R1’s Admission Agreement and found that on page 13, subsection 6, titled, “Absences” stated, “If you are absent from LAS VILLAS DEL NORTE for more than fourteen (14) consecutive days, you will receive a pro-rated credit toward your Monthly Care Fee starting on day fifteen (15).” *This is an amended version of the original report. SubstantiatedRead the full finding— CDSS inspection report, January 4, 2024 · control 18-AS-20230728094657

Licensing Program Analyst (LPA), Jacqueline Shaw Ross made an unannounced visit to the facility to commence a complaint investigation regarding the allegation listed above. LPA met with Jolene Farish, Executive Director and explained the purpose of the visit and the elements of the allegation. During the investigation, LPA Shaw-Ross conducted interviews with five (5) residents, and five (5) staff members, that included the facility chef. The investigation also consisted of observation and record review. LPA was unable to interview additional witnesses due to not being able to obtain contact. On 9/28/2023, Community Care Licensing received a complaint alleging the facility does not have an adequate food supply. Of all five (5) residents interviewed, four (4) stated there was a supply of plenty of food and that food served was adequate. One (1) resident (R5), corroborated the allegation by stating they have a new chef and the food has not been so great. R5 further stated the kitchen stafRead the full finding— CDSS inspection report, December 1, 2023 · control 18-AS-20230928103442

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Ana Cruz, Resident Services Director and explained the purpose of the visit. Regarding the allegation "Resident is severely neglected", it was alleged on 5/16/2023, Resident #1 (R1) had been found covered in dried feces. Review of R1's Progress Notes dated 5/16/2023 revealed during rounds, and ten minutes prior to the incident, R1 was observed to be free of feces as they sat in the hallway. Two (2) of six (6) staff interviewed reported R1 had one (1) or two (2) instances of removing feces from their incontinent garment. LPA attempted to interview R1 however, R1 did not verbally respond to LPA's presence or inquires. Interview with R1's responsible party revealed they are happy with the care R1 is provided. Regarding the allegation "Resident is unsupervised", it was alleged R1 had been found sitting alone without the presence oRead the full finding— CDSS inspection report, September 19, 2023 · control 18-AS-20230518160952

On 1/4/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced complaint visit to deliver an amended version of this report. LPA met with Administrator, Jolene Farish. Regarding the allegation of “Staff are not providing resident with a refund” it was alleged that Resident 1 (R1) did not receive a refund for monthly care fees overcharged during R1’s absence from the facility. LPA reviewed R1’s Admission Agreement and found that on page 13, subsection 6, titled, “Absences” stated, “If you are absent from LAS VILLAS DEL NORTE for more than fourteen (14) consecutive days, you will receive a pro-rated credit toward your Monthly Care Fee starting on day fifteen (15).” *This is an amended version of the original report UnsubstantiatedRead the full finding— CDSS inspection report, August 3, 2023 · control 18-AS-20230728094657

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Resident Care Director Ana Cruz and Memory Care Director Klarrisa Romero and explained the purpose of the visit. Regarding the allegation “Resident pushed out of wheelchair and sustained a shoulder fracture due to lack of supervision”, it was alleged that Resident #1(R1) was pushed out of their wheelchair by two unknown women resulting in a shoulder fracture. Interview conducted with Memory Care Director Ana Cruz revealed R1 was admitted to the facility in 2019, was ambulatory at times and utilized a wheelchair other times due to personal preference. Review of R1’s Preplacement Appraisal dated 10/13/2019 revealed R1 was able to transfer to and from bed without assistance. Review of R1’s 90 day Level of Care Assessment dated 01/07/2020 and 180 day Level of Care Assessment dated 07/05/2021 revealed R1 was able to transfer indepeRead the full finding— CDSS inspection report, May 23, 2023 · control 18-AS-20221209153932

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Executive Director(ED) Jolene Farish and Memory Care Director(MCD) Ana Cruz and explained the purpose of the visit. During today's visit, LPA interviewed three(3) staff. Regarding the allegation "Personal Rights Violation", it was alleged that Residents #1(R1) and #2(R2) had accumulated approximately four(4) months of mail dating back to at least October 2022 at the facility and was not provided to them or their responsible party. Interviews conducted with facility staff indicated that mail is supposed to be given to the responsible party during times of visit by the front desk staff if the resident is incapable of handling the mail. Interview conducted with R1 and R2's responsible party revealed they were not aware mail was accumulating at the facility. Interview conducted with R1 and R2's family representative revealed they haRead the full finding— CDSS inspection report, February 16, 2023 · control 18-AS-20230213152700

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude a complaint investigation into the allegation list above. LPA met with Memory Care Director Ana Cruz and informed her of the purpose of the visit. Regarding the allegation "Staff did not answer the resident's call button in a timely manner", it was alleged that on May 14, 2022, Resident #1(R1) activated their call button and waited over thirty(30) minutes for staff to respond. Records reviewed indicated that on May 14, 2022, R1 activated their call button a total of six(6) times. R1's call button activation on May 14, 2022 at 11:06 AM resulted in a staff response time of thirty-five(35) minutes and eleven(11) seconds. R1's call button activation on May 14, 2022 at 2:38 PM resulted in a staff response time of thirty-nine(39) minutes and eleven(11) seconds. R1 could not be interviewed. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegatioRead the full finding— CDSS inspection report, January 25, 2023 · control 18-AS-20220922143233

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Memory Care Director Ana Cruz and explained the purpose of today's visit. This visit was incorrectly identified as having been conducted 1/24/2023. The visit was actually conducted 1/25/2023. *This is an amended report. Regarding the allegation "Staff do not properly supervise residents", it was alleged that memory care residents were left unsupervised and then wandered into Resident #1's (R1) room and interupted R1's visit with family. Interviews conducted with staff indicated approximately ten(10) to twelve(12) residents are assigned to each caregiver during AM shift, ten(10) to fifteen(15) residents are assigned to each caregiver during PM shift, and fifteen(15) residents are assigned to each caregiver during NOC shift. There are four(4) additional staff assigned to memory care each AM shift to assist and supervise residentRead the full finding— CDSS inspection report, January 24, 2023 · control 18-AS-20220602121633

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigaton into the allegations listed above. LPA met with Executive Director Jolene Farish and explained the purpose of the visit. During today's visit, LPA interviewed one(1) staff. Regarding the allegation "Insufficient staffing to meet resident's needs", it was alleged that the needs of residents in the memory care unit were not being met due to a lack of staffing due to a high turnover rate. Interviews conducted with six(6) memory care residents revealed three(3) of six(6) memory care residents reported their needs were met or exceeded by the staff in the memory care unit. Three(3) of six(6) memory care residents were unable to be qualified to be reliable witnesses. Interviews conducted with five(5) memory care staff revealed four(4) to five(5) staff are scheduled for each AM shift, three(3) to four(4) staff are scheduled for each PM shift, and two(2) to three(3) staff are scheduleRead the full finding— CDSS inspection report, January 6, 2023 · control 18-AS-20220712101108

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Executive Director Jolene Farish and explained the purpose of the visit. Regarding the allegation "Staff did not respond to resident's call for assistance in a timely manner", it was alleged that when Resident #1(R1) activated their call pendant, it took staff forty(40) minutes to one(1) hour to respond. It was further alleged that R1 had fallen from their scooter on one occasion and waited for hours on the floor for assistance. Interviews were conducted with ten(10) residents. Nine(9) of ten(10) residents reported facility staff do respond to call lights in a timely manner. One(1) of ten(10) residents interviewed has not utilized the call light system. However, records reviewed indicated R1 activated their call light thirty-seven(37) times in the period in question. Only forteen(14) of R1's thirty-seven(37) call lights were resRead the full finding— CDSS inspection report, January 6, 2023 · control 18-AS-20220720173917