Sutro Heights

Type of visit: Case Management - Deficiencies

LPAs Calandra and Jeung observed deficiencies of the California Code of Regulations, Title 22, which are cited on a following page.the state’s words, verbatim · CDSS document, Oct 2, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Oct 3, 2023

FIRE SAFETY All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met, as a wall is erected between first 2 rooms. Fire clearance was approved for one large room. There is a window in one of the rooms, but not the room closest to the street. Licensee failed to ensure conformity with fire clearance, which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: Wall separating first 2 front rooms on ground level will be eliminated. Proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87307(d)(6) · Plan of correction due date: Oct 3, 2023

PERSONAL ACCOMMODATIONS/SVCS All outdoor and indoor passageways and stairways shall be kept free of obstruction. In the ground level passageway leading from street to backyard, there are boxes, filled plastic bags and tables obstructing free and clear exiting. In addition, overgrowth of plants limits the width of passageway to backyard. Licensee failed to ensure that passageway is free of obstruction, which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: Ground level passageway shall be free of obstructions and access to backyard shall be available to wheelchairs. Proof of correction to be sent to CCLD BY DUE DATE.

Type of visit: Case Management - Deficiencies

Deficiencies of the California Code of Regulations, Title 22 are observed during investigation of complaints, and are cited on following pages.the state’s words, verbatim · CDSS document, Sep 13, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1) · Plan of correction due date: Sep 14, 2023

MAINTENANCE AND OPERATION Facilities shall have signal systems which shall meet the following criteria: ...having separate floors or buildings shall have a signal system which shall operate from each resident's living unit, transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff, identify the specific resident living unit. This requirement is not met, as 3 out of 5 rooms on ground floor and 4 out of 5 rooms on 2nd floor do not have call system. Licensee failed to ensure that emergency call system is installed, which poses an immediate health & safety risk to clients in care.the state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: Emergency call system shall be installed and operable in each clients' room, identify the room of origin and transmit auditory alert to summon staff. Proof of correction to be submitted to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type A · Section cited: CCR87204(a)(b) · Plan of correction due date: Sep 14, 2023

LIMITATIONS CAPACITY/AMBULATORY STATUS A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including... Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. This requirement is not met, as client #1 is non-ambulatory and resides in room on 2nd level. Licensee failed to adhere to limitations of ambulatory status, which poses an immediate health and safety risk to clients in carethe state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: Plan/proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(c) · Plan of correction due date: Sep 20, 2023

PERSONAL ACCOMMODATIONS AND SERVICES Individual privacy shall be provided in all toilet, bath and shower areas. This requirement is not met, as commode is in use in 2nd floor shared room of client #1. Licensee failed to ensure privacy when toiletting for clients in shared room, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: Plan/proof of correctuion to be sent to CCLD by DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465 · Plan of correction due date: Sep 20, 2023

INCIDENTAL MEDICAL CARE (h)(6) A record of centrally stored Rx medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions: This requirement is not met, as there is no Centrally Stored Medication Records for staff #1 and #2. Licensee failed to ensure that CSMR is maintained for clients' medications, which poses a potential health, safety or personal rights risk to clients.the state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: Plan/proof of corrections to be submitted to CCLD BY DUE DATE

Allegation investigated: Facility staff do not ensure that resident's room is ventilated. Facility staff are not adequately trained. Resident's wheelchair has gone missing. Facility staff left the kitchen medicine cabinet unlocked. Facility staff did not provide resident a list of their belongings upon request. Facility staff leave resident restrained in their bed all day long. Facility staff did not ensure that resident had appropriate size bed linens and blankets that are cleaned. Facility staff mishandled resident's records. Facility staff did not provide resident appropriative medical supplies. Facility staff did not ensure that resident's hygiene needs are being met. Facility staff does not speak language that resident understands. Facility staff did not ensure that resident's food/drinks are served at the right temperature and offered resident

On July 5, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230414140716. LPA met with manager, Oscar Madrigal and explained the purpose to today's visit. Regarding to allegation of - facility staff do not ensure that resident's room is ventilated, the reporting party stated that that resident #1 (R1) was transferred to a room without ventilation. As part of the investigation, LPA interviewed R1, facility staff, and former assistant administrator. During the initial complaint visit, LPA observed staff was providing a sponage bath to R1 in the room with the door closed and afterwards, LPA observed the room to be stuffy. LPA interviewed R1 who stated that the room is unventilated when staff failed to open the door after they are done with providing care. Substantiated According to facility staff, when they were providing care to R1, they closed the door to ensure R1's privacy and dignity are maintained but they also acknowledged that the room is unventilated when the door is closed. The former assistant administrator acknowledged R1's room needed additional ventilation and the facility was considering getting a permit to install a window. After the investigation, this allegation is deemed to be substantiated. Regarding to allegation of- facility staff are not adequately trained, the reporting party stated that facility staff stated that they are not trained to use the hoyer lift. As part of the investigation, LPA interviewed staff, requested for training records and interviewed resident #1 (R1). LPA interviewed R1's caregivers regarding training on hoyer lift and both of them reported that they were not trained and they did not know how to use it. According to the facility manager, there is no training records on hoyer lift. LPA interviewed R1 who was in bed and required a hoyer lift for transfer. According to R1, R1 has been in bed for many months because facility staff did not know how to use the hoyer lift to get R1 out of bed. After the investigation, this allegation is deemed to be substantiated. Regarding to allegation of- resident's wheelchair has gone missing, the reporting party stated that R1's family member provided R1 a manual wheelchair in March 2022, however it has gone missing. As part of the investigation, LPA interviewed R1 and staff. During the initial complaint visit on 4/20/2023, LPA interviewed R1 who stated that staff mistakenly handed over R1's wheelchair to a medical equipment company when the equipment company came to collect medical equipment for another resident. In addition, R1 stated that R1 has made contacts with the medical equipment company and they would return the wheelchair in a few days. LPA interviewed staff #1 (S1) who stated that they thought R1's wheelchair belonged to another resident, therefore, they returned it to the company when they came. After the investigation, this allegation is deemed to be substantiated. Regarding to allegation of- facility staff left the kitchen medicine cabinet unlocked, during the initial complaint visit on 4/20/2023 at 11:50am, LPA observed the kitchen medicine was not locked and there was no staff present at the time to monitor. After the investigation, this allegation is deemed to be substantiated. Regarding to allegation of- facility staff did not provide resident a list of their belongings upon request, the reporting party reported R1's family member brought a wheelchair to the facility for R1 and R1 asked the former manager to put it on the belonging list. R1 requested staff to see the belonging list but it was never provided. As part of the investigation, LPA interviewed R1, interviewed facility manager and reviewed record. According to R1, R1 has requested to reviewed R1's belonging list but it has yet been provided. Therefore, R1 was unsure if the wheelchair was added to the belonging list or not. LPA reviewed R1's client/ resident personal property and valuables (LIC 612) and it was blank. Facility newly hired manager acknowledged that R1's belonging list was mostly not provided to R1 for review as it was blank and inaccurate. After the investigation, this allegation is deemed to be substantiated. Regarding to allegation of- facility staff leave resident restrained in their bed all day long, the reporting party stated that facility staff was not trained on how to use the hoyer lift to transfer R1 from bed to wheelchair. Therefore, R1 was restrained to the bed which resulted R1 has not seen the sun for over 6 months and R1 just wanted to get some fresh air. As part of the investigation, LPA interviewed R1, interviewed facility staff and reviewed records. During the initial complaint visit on 4/20/2023, LPA observed R1 in bed, and R1 stated that R1 stayed in bed all day long as facility staff did not know how to use a hoyer lift to transfer R1 from bed to wheelchair. In addition, R1 stated that while R1 was receiving therapy from a home health agency, the therapist(s) trained facility staff on how to use a hoyer lift but most them are no longer working at the facility except for one but whenever he/she is scheduled to work, he/she claimed to be too busy and did not have time to get R1 out of bed. According to S1 and staff #2 (S2), R1 stayed in bed all the time as R1 required to be transferred from bed to wheelchair with a hoyer lift and they were not trained on how to use it. According to R1's appraisal/needs and service plan, R1 required two person assist, R1 needs hoyer lift for transfer and under method of evaluating progress, it indicated that resident will show no signs and symptoms of isolation, and resident will participate with activities. However, facility failed to execute R1's appraisal/needs and service plan as staff was not trained on using a hoyer lift for transfers resulted R1 to be confined in bed. After the investigation, this allegation is deemed to be substantiated. Regarding to allegation of facility staff did not ensure that resident had appropriate size bed linens and blankets that are cleaned- the reporting party stated that R1 reported that the bed linens and top upper blankets have not been changed for over 3 weeks. The reporting party observed bed sheets were stained, and bed sheets were not the right size. As part of the investigation, LPA interviewed facility staff, and R1. During the initial complaint visit on 4/20/2023, LPA observed stains on R1's bed linens, and the linen was tugged underneath the mattress. According to R1, facility staff did not change the beddings for a couple of weeks and they stated that they did not have any cleaned beddings. LPA interviewed S1 who reported that facility did not have any extra cleaned linens. LPA observed there was no cleaned linens in the linen storage room. According to the newly hired manager who acknowledged that facility did not have any linens/beddings in storage as the facility used all the supplies a few days ago when a resident had many episodes of diarrhea. After the incident, the facility discarded the soiled linens resulted no additional linens but facility is in process of purchasing new linens/beddings. After the investigation, this allegation is deemed to be substantiated. Regarding to allegation of facility staff mishandled resident's records- the reporting party stated that R1 suffers from constipation and facility staff was supposed to document on a log that was posted by R1's bed whenever R1 had a bowel movement. However, facility staff constantly failed to document it, therefore, it made it difficult for R1 to get the constipation medicine as there was no records showing when R1 had a bowel movement. As part of the investigation, LPA interviewed R1, facility staff, manager and review the log. Based on the March 2023 and April 2023 vital signs and ADL's logs, it revealed R1 did not have any bowel movements within those 2 months. According to R1, R1 always reminded facility staff to document on the log whenever R1 had a bowel movement and they would verbally agree to do it but they would forget. LPA interviewed facility staff who acknowledged that they failed to document properly when R1 had a bowel movement. LPA interviewed the newly hired manager who acknowledged the log was inaccurate as facility staff failed to document whenever R1 had a bowel movement as they should. After the investigation, this allegation is deemed to be substantiated. Regarding to allegation of facility staff did not provide resident appropriate medical supplies, the reporting party stated that R1 performed blood sugar testing a few times a day and the facility staff did not provide R1 with alcohol wipes for the procedure instead, facility staff offered toilet paper or napkins as facility staff stated that they did not have any alcohol wipes available. As part of the investigation, LPA interviewed R1 and facility staff. During the initial complaint visit on 4/20/2023, LPA observed facility did not have any alcohol wipes as house supplies instead staff provided 2 boxes of alcohol wipes with another resident's name it. According to staff, they did not provide alcohol wipes for R1 when R1 was performing blood sugar checks. According to R1, staff instructed R1 to use toilet paper or baby wipes to sanitize R1's finger while doing blood sugar checks. R1 asked for alcohol wipes and R1 was told numerous times by facility staff that they did not have any. After the investigation, this allegation is deemed to be substantiated. Regarding to allegation of facility staff did not ensure that resident's hygiene needs are being met, the reporting party stated that R1 has not had a hair shampoo for 3 weeks, has not had a shave, and has not gotten assistance with brushing teeth. As part of the investigation, LPA interviewed R1, newly hired manager, facility staff and reviewed documentation. According to R1, R1 has not gotten a shower for many, many weeks instead R1 was provided with sponge baths daily. However, during sponge baths, they did not provide hair shampoo and in order for R1 to brush teeth and to shave, R1 had to request for it during the sponge baths. In addition, when R1 requested a hair shampoo, facility staff would agree to it and asked R1 to wait but often they forgot or claimed they were too busy to assist R1. According to newly hired manager, shaving, shampooing hair and brushing teeth are routine tasks that should be performed as part of the sponge bath and there was no need for residents to request for it. According to S2, R1 gets a sponge bath on a daily basis which did not include shaving, brushing teeth and shampooing hair unless it was requested by R1. However, S2 acknowledged that these tasks should be included and residents did not have to ask for it. Based on R1's appraisal/needs and services plan, R1 required assistance with ADLs (Activities of Daily Living). After the investigation, this allegation is deemed to be substantiated. Regarding to allegation of- facility staff does not speak language that resident understands, the report party stated the caregivers always speak in their language in front of R1. As part of the investigation, LPA interviewed R1 and other residents. According to R1, facility staff always talked in a language that R1 did not understand which made R1 felt uncomfortable. R1 reminded staff to speak English while talking in front of R1 and they verbally agreed but they continued to talk in a language that R1 did not understand. During the initial complaint visit on 4/20/2023, LPA observed 2 female staff speak in their language in front R1's door while R1 was in bed. LPA interviewed other residents who stated that they have also experienced facility staff spoke in a language that they did not understand in front of them but it was not an issue for them. After the investigation, this allegation is deemed to be substantiated as it did not bother the other residents but it made R1 felt uncomfortable. Regarding to allegation of facility staff did not ensure that resident's food/drink are served at the right temperature, the reporting party stated that R1 received cold to lukewarm food every day such as cold boiled eggs, cold oatmeal twice a week and cold English muffin. In addition, R1 has told facility staff that R1 did not like receiving cold food items but R1 continued to get them. As part of the investigation, LPA interviewed R1, other residents, newly hired manager and the administrator. According to R1, the food is always served lukewarm or cold especially for breakfast. R1 expressed frustration with asking staff to heat it up on a daily basis and stated that the food quality was not the same after being in the microwave. R1 wanted the hot foods to be served hot. LPA interviewed other residents regarding to temperature of the food and they reported that sometimes it was cold and they had to ask staff to heat it up but that was not an issue for them. One of the residents stated the meals were being prepared ahead of time resulted temperature not being maintained. LPA interviewed facility manager and administrator who acknowledged that breakfast is being cook too early, therefore, the temperature was not being maintained when served. Both of them stated that they will revisit the breakfast workflow and make adjustments to ensure residents are being served hot meals. After the investigation, this allegation is deemed to be substantiated. Based on interviews, observation and record reviews during the course of investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was reviewed and discussed with manager, a copy is provided and Appeal Rights provided. During the initial visit, LPA observed a slight urine odor inside of R2's room but odorless by the hallway. After the investigation, this allegation is deemed to be unsubstantiated as facility staff acknowledged that there was an odor smell at times, however, it was due to a resident who was refusing to be cleaned but they were encouraging resident to be compliant with care. Regarding to facility staff does not respond to a resident's calls for assistance, there is no additional information forthcoming from the reporting party. However, R1 stated that R2 yelled and screamed at night and no one attended to R2. As part of the investigation, LPA interviewed facility staff and observed R2. During the initial complaint investigation on 4/20/2023, LPA observed R2 in bed, sleeping and when staff gently attempted to initiate a conversation, R2 became combative and agitated. According to facility staff, R2 screamed and yelled on and off during the night and slept during the day. They also stated that they were aware that R2's behavior was disruptive to other residents such as R1. Therefore, they stayed close to R2's room during the night so they could monitor R2 closely. After the investigation, this allegation is deemed to be unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is discussed and review with manager. A copy is provided. LPA interviewed facility staff who reported that currently R1 does not have any skin rashes and they apply cream to prevent rashes and other skin conditions. LPA interviewed the former assistant administrator who stated that R1's pressure ulcer and rashes were treated by a home health agency until healed. After the investigation, this allegation is deemed to be unfounded. Regarding to allegation of- facility staff did not ensure that resident received their medication on a timely basis, there is no additional information forthcoming from the reporting party. As part of the investigation, LPA interviewed R1, other residents, and staff. R1 stated sometimes the medication was given late but R1 was not able to provide additional details. LPA interviewed facility staff and they reported that they administered R1's medication on time. LPA interviewed 3 residents and all of them reported that their medication(s) arrived on time and they had no concerns. LPA observed the medication administration records to be adequate. After the investigation, this allegation is deemed to be unfounded. Regarding to allegation of facility staff did not notify resident change of room- during the initial reporting, the reporting party stated that R1 was hospitalized in March 2023 and when R1 returned, R1 was moved to a small room and unventilated. As part of the investigation, LPA interviewed R1, facility staff, former assistant administrator, and administrator. LPA interviewed R1 who provided the same details as the reporting party but clarified that the hospitalization was in 2022 and not 2023. R1 was not able provide the room number and/or the location of the room that R1 has resided prior to the hospitalization. LPA interviewed 6 facility staff including one of them who has been employed prior to R1's admission and all of them stated that R1 was not moved to a different room after being hospitalized in 2022. LPA interviewed the administrator and the former assistant administrator and both of them denied the allegation and stated that R1 returned to the same room after R1's hospital stay in 2022. After the investigation, this allegation is deemed to be unfounded. This agency has investigated these complaints and we have found that the complaints were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report is reviewed and discussed. A copy is provided.the state’s words, verbatim · CDSS document, Jul 5, 2023 · control 14-AS-20230414140716

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 14, 2023

87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:..(2)To be accorded safe, healthful and comfortable accommodations,.. This requirment is not met as evidenced by facility did not ensure R1's room was ventilated, facility failed to get R1 up from the bed so R1 could enjoy fresh air and sunshine outside of R1's room; faciliy did not ensure R1 had cleaned andthe state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The administrator/licensee and/or designee will develop a plan to ensure R1's care is being met and R1's appraisal/needs and service plan is followed by facility staff. This plan will include staff education. The administrator/licensee and/or designee will provide a copy of this plan and a copy of facility staff in-service sign-in record to CCL by 7/14/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 14, 2023

CONT... well fitted linens/beddings; facility failed to provide proper supply to R1 prior to R1 performing self blood sugar checks and R1 felt uncomfortable when staff conversing in front of R1 in a language that R1 did not understand, and facility left R1 in bed all the day long which posed potential health risks to resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 14, 2023

87411 Personnel Requirements - General..a) Facility personnel shall at all times be sufficient..and competent to provide the services necessary to meet resident needs...This requirement is not met as evidenced by facility staff was not trained on how to use a hoyer lift resulted R1 not getting out of bed for many months which posed a potential risk for resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The administrator/licensee and/or designee will develop a plan to ensure facility staff is properly trained to use equipment that is required to care for residents. The plan needs to include when facility staff will be trained and who will be providing the training. The administrator/licensee and/or designee will provide a copy of the plan and a copy of the in-service sign-in record to CCL by 7/14/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jul 14, 2023

87217 Safeguards for Resident Cash, Personal Property, and Valuables..(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables This requirement has not been met as evidenced by facility mistakenly handed R1's personal wheelchair to a equipment company when they came to pick up equipment for another resident which posed a potential risk for resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The administrator/licensee and/or designee will develop a plan to ensure this does not happen again and the plan shall include staff education. The administrator/licensee shall provide a copy of the plan and a copy of the staff education sign-in record to CCL by 7/14/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jul 14, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities,..(19) To have prompt access to review all of their records ... This requirement is not met as evidenced by R1 requested to review R1's inventory list, however, it was not provided which poses a potential risk for resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The administrator/licensee and/or designee will develop a plan to ensure this does not happen again and the plan shall include staff education. Facility will provide a copy of the plan and staff education sign-in sheet to CCL by 7/14/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jul 14, 2023

87506 Resident Records.. a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirment is not met as evidenced by facility staff failed to complete R1's ADL log which poses a potential risk for resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The administrator/licensee and/or designee will develop a plan to ensure facility staff complete resident's records accordingly and the plan shall include staff education. Facility will provide a copy of the plan and staff education sign-in sheet to CCL by 7/14/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jul 7, 2023

87465 Incidental Medical and Dental Care..(h) The following requirements shall apply to medications which are centrally stored:..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 requirement is not met as evidenced by during the 10-day complaint visit, LPA Han observed the medication storage in the kitchen was not locked and there were no staff present which poses an immediately risk to resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The administrator/licensee and/or designee will develop a plan to ensure medication storage is lock and inaccessible to residents in care and the plan shall include staff education. The administrator/licensee will submit a copy of the plan to CCL by 7/7/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Jul 14, 2023

87464 Basic Services..(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs.. This requirement is not met as evidenced by facility staff failed to provide R1 ADL care during bed bathes which poses a potential risk for resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The administrator/licensee and/or designee will develop a plan to ensure this does not happen again and the plan shall include staff education. Facility will provide a copy of the plan and staff education sign-in sheet to CCL by 7/14/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(5) · Plan of correction due date: Jul 14, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities..(a) In addition to the rights listed in Section 87468.1,..(5) To be served food of the quality and quantity necessary to meet their nutritional needs. This requirement is not met as evidenced by facility severed R1 cold meals which poses a potential risk for resident in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: The administrator/licensee will develop a plan to ensure this does not happen again and the plan shall include staff education. Facility will provide a copy of the plan and staff education sign-in sheet to CCL by 7/14/2023.

Allegation investigated: Facility staff not maintaining resident’s hygiene. Facility staff serves cold meal(s) to resident. Facility staff not keeping resident’s legs free from pests.

On 4/20/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230203085150. LPA met with manager, Oscar Madrigal and explained the purpose to today's visit. Regarding to the allegation of facility staff not maintaining resident's hygiene, the reporting party stated that resident #1 (R1) was not showered in 20 days. As part of the investigation, LPA interviewed R1, other residents, facility staff and reviewed records. According to R1, R1 was not showered for a long time but R1 was provided with a bed bath 2-3 times per week. According to resident #2 (R2), R2 was supposed to get a shower at least once a week but R2 has only gotten one in 8 weeks but R2 was provided with a bed bath almost daily. According to resident #3 (R3), R3 did not remember when facility staff provided him/her a shower but R3 was provided with a bed bath a few times a week and R3 preferred having showers every week. Based on the facility's shower schedule, R1, R2 and R3 were supposed to be showered every week. Based on December 2022 and January 2023 vital signs and Activities of Daily Living (ADLs) logs for R1, R2 and R3, LPA observed under the shower slots, there were all blank and facility staff reported it was an indication that shower was not provided. According to staff #1 (S1) and staff #2 (S2), facility provided R1, R2, and R3 bed baths but not showers. After the investigation, this allegation is deemed to be substantiated. Substantiated Regarding to the allegation of facility staff serves cold meals to resident, the reporting party stated that R1 was served a lot of cold meals and facility was not following R1's diet needs. As part of the investigation, LPA interviewed R1, other residents and facility staff. According to R1, the facility is following the diet restriction and R1 liked the foods but sometimes it was served cold. According to R2, R3, and resident #4 (R4), the food was good but it was served cold and they had to request facility staff to heat it up. LPA interviewed S1 who stated that he/she was not aware that the meals were served cold but many residents asked it to be heated up. After the investigation, this allegation is deemed to be substantiated. Regarding to the allegation of facility staff not keeping resident's legs free from pests- the reporting party stated that there were ants crawling on R1's toes and knees. As part of the investigation, LPA interviewed R1, staff and hospice nurse. According to R1, there were ants crawling on R1's toes. LPA interviewed S1 who acknowledged that there were ants observed to be crawling on R1's toes and it was reported to the administrator. According to hospice nurse, there were ants on R1's bed and by R1's lower extremity. After the investigation, this allegation is deemed to be substantiated. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, a copy is provided and Appeal Rights provided. LPA interviewed facility staff and both of them were aware R1 and R2's special dietary needs and they stated that they followed it every meal. After the investigation, this allegation is deemed to be unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is discussed and review with manager. A copy is provided.the state’s words, verbatim · CDSS document, Apr 20, 2023 · control 14-AS-20230203085150

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Apr 21, 2023

87464 Basic Services..(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified .. This requirement is not met as the facility did not assist resident with showers for many weeks as scheduled which poses an immediately health risk to resident in care.the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: The administrator/licensee will develop a plan to ensure residents are provided with showers according to the schedule. The administrator will submit a copy of the plan and a copy of the shower schedule to CCL by 4/21/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.19a)(2) · Plan of correction due date: Apr 21, 2023

87468.1 Personal Rights of Residents in All Facilities..a) Residents in all residential care facilities for the elderly shall ...(2) To be accorded safe, healthful and comfortable accommodations,... This requirement is not met as evidenced by S1 and home health staff acknowledged that they have observed pest crawling on R1's lower extremity and on the bed which poses an immediately health risk for resident in care.the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: The administrator/licensee will develop a plan to ensure residents are being cared for in a comfortable, healthful and sanitized environment. The administrator will submit a copy of the plan to CCL by 4/21/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(5) · Plan of correction due date: Apr 27, 2023

87468.2 Additional Personal Rights of Residents...(5)To be served food of the quality and quantity necessary to meet their nutritional needs. This requirment is not met as evidenced by residents are experiencing being served cold meals which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: The administrator/Licensee will develop a plan to ensure residents are being served quality food and the plan needs to indicate who is going to ensure compliance. The administrator/licensee will submit a copy of the plan of correction to CCL by 4/27/2023.

Allegation investigated: Resident left in soiled diaper for an extended amount of time.

On 2/8/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20221025152849. LPA met with manager, Oscar Madrigal and explained the purpose to today's visit. Regarding to allegation of- resident left in soiled diaper for an extended amount of time, there is no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that during a visit, resident #1 (R1) was in soiled clothing and the reporting party had to change R1. . The administrator denied the allegation and stated that staff documents on a log whenever care is provided to R1 such as turning and repositioning, providing incontinent care, changing and cleaning R1, etc. and the log is placed in R1's room. During the initial 10-day visit on 11/3/2022, LPA observed R1 to be cleaned, appeared to be calm and comfortable. In addition, LPA observed a log on R1's bedside table with documentation by staff when care is rendered on a daily basis. Unsubstantiated According to staff #1 (S1), due to R1's health condition, they check and they anticipate R1's needs several times a day. According to a nurse from an outside agency who visits R1 on a weekly basis, facility staff keeps R1 clean and comfortable during the visit, he/she has not observed R1 to be soiled and staff assists he/she with caring for R1 whenever is needed. Based on interviews, observation, and record review during the course of the investigation, this allegation is deemed to be unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is discussed and reviewed with the manager. A copy is provided.the state’s words, verbatim · CDSS document, Feb 8, 2023 · control 14-AS-20221025152849

Allegation investigated: Staff do not answer residents' call bells in a timely manner

On 2/8/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20221026144655. LPA met with manager, Oscar and explained the purpose to today's visit. Regarding to allegation of - staff do not answer residents' call bells in a timely manner, there is no additional details forthcoming from the reporting party, however, during the initial reporting, the reporting party stated that sometimes it takes staff ten minutes to answer call bell due to staffing challenges. As part of the investigation, LPA interviewed the administrator who denied the allegation and stated that the facility is having adequate staffing to meet resident's needs. LPA interviewed 5 residents and all of them reported that facility staff are responding to their calls timely, and sometimes it takes a littler longer because they are helping other residents but overall, their needs are being met. Based on observation, and interviews during the course of the investigation, this allegation is deemed to be unsubstantiated. Unsubstantiated Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is discussed and review with manager. A copy is provided.the state’s words, verbatim · CDSS document, Feb 8, 2023 · control 14-AS-20221026144655

Type of visit: Required - 1 Year

On 2/8/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by manager, Oscar Madrigal. LPA explained the purpose of the visit and LPA was screened at the front entrance. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies. there are 12 residents at the facility and the beds in the shared rooms are observed to be 6" apart. There are 4 staff and manager on duty during the visit. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, hand washing instruction is posted by the hand washing stations. Trash cans are recommended to have foot operated lids. Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete. There are 6 residents, and 1 staff member ( the other staff is on break) present during the inspection. During today's tour at 10:15AM, LPA observed resident #1(R1) and resident #2(R2)'s room to be uncleaned and unsanitary. LPA observed several spider webs and one with a spider on it around the window by R2, dust and many dead ants on the baseboard behind R2's bed and soiled tissue paper on the floor next to R2's bed. In addition, LPA observed black particles in R1's drawer, shape appears to be similar to mouse droppings. According to R1 and R2, there is an ant infestation in their room and it was reported to the administrator. LPA shared the observation with manager who instructed staff to clean the room immediately. Based on observation, deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed with manager. A copy of this report and appeal rights are provided.the state’s words, verbatim · CDSS document, Feb 8, 2023

Allegation investigated: Staff are not following resident's Admissions Agreement. Resident's Representative did not receive a copy of their Admissions Agreement. Staff are not responding to Resident's Representative's requests for communication in a timely manner.

On 10/20/2022. Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220930104518. LPA met with the administrator, Juliet Pacaldo and explained the purpose to today's visit. Regarding to allegations of- staff are not following resident's admission agreement, and staff are not responding to Resident's Representative's requests of communication in a timely fashion, there was no additional information forthcoming from the reporting party. However, after speaking to the family member of resident #1 (R1), both allegations were pertaining to the unused portion of the monthly fee for R1 that has yet been refunded to the responsible party per the admission agreement. According to the family member, R1 stayed at the facility for a few days in January, 2022 and passed away, the facility did not follow the admission agreement pertaining to its refund policy and the former facility manager did not provide a closure to the communication exchanges as the former facility manager agreed to refund the unused portion of the monthly fee to R1's responsible party but it has not been done. Substantiated As part of the investigation, LPA requested for a copy of R1's admission agreement and the facility was not able to provide it. According to the staff #1 (S1), the facility did not have a copy of the admission agreement on file and the former facility manager has it. This is a deficiency and will be cited on LIC 809 under Admission Agreement as the facility shall retain the original signed and dated admission agreement in resident's file. LPA interviewed the former facility manager who acknowledged that the facility has yet refunded the unused portion of the payment to R1's responsible party as the facility has made several attempts to refund R1's remaining balance to R1's responsible party but there was no success. The former facility manager agreed to provide written communication to CCL to show that attempts were made for the refund and a copy of R1's signed admission agreement. However, CCL has not received any documents from the former facility manager. Based on the facility's standardized admission agreement, it states that refund would be issued in 30 days following the effective termination date. Based on interviews and documents provided, this allegation is deemed substantiated as R1 passed away in January 2022 and the refund of the unused portion of the payment for January 2022 has not been issued and received by the responsible party. Regarding to allegation of- resident's representative did not received a copy of the admission agreement, according to the family member, R1's responsible party signed some admission paper work and requested for a copy of the signed documents several times but has yet received it. As part of the investigation, LPA interviewed the former facility manager who stated that a copy of the admission agreement was emailed to the responsible party and will provide a copy to CCL. However, this information was not provided.. After the investigation, this allegation is deemed substantiated as the facility was not able to provide proof that a copy of the signed and dated admission agreement and all subsequent signed and dated modifications, to the resident or the resident's representative. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, a copy is provided and Appeal Rights provided.the state’s words, verbatim · CDSS document, Oct 20, 2022 · control 14-AS-20220930104518

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.652(c) · Plan of correction due date: Oct 27, 2022

§1569.652 Termination of admission agreement upon death of resident;...(c) A refund of any fees paid in advance....within 15 days after the personal property is removed. This requirement is not met as evidence by: In January 2022, R1 stayed at the facility for a few days and the responsible party paid for the entire month but the facility has yet refunded the unused portion of the payment to the RP poses a potential risk to person(s) in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: The Administrator and/or Licensee will refund the unused balance to R1's responsible party by 10/27/2022. The Administrator and/or Licensee will review the regulation and provide a signed written statement after the review and submit it to CCL by the plan of correction due date 10/27/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Nov 3, 2022

87507 Admission Agreements..(e) The licensee shall provide a copy of the signed and dated current admission agreement,..to the resident or the resident's representative, The requirment is not met as evidenced by: The facility did not provide a copy R1's admission agreement to R1's responsible party despite R1's responsible party's requests which poses a potential risk to person(s) in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: The Administrator and/or Licensee will review the regulation and provide a signed written statement of acknowledgement of the review and the administrator and/or the licensee will submit a plan to ensure compliance by the plan of correction due date 11/3/2022.

Allegation investigated: Staff yell at resident in care. Staff do not treat resident with dignity and respect.

On 10/20/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220914194750. LPA met with the administrator and explained the purpose to today's visit. Regarding to allegation of staff yelled at resident in care, the reporting party stated that staff yelled at resident #1 (R1) on several occasions and it was witnessed by the reporting party. As part of the investigation, LPA interviewed R1 who stated that there is one staff (staff #1) yelled at R1 and other residents if they did not comply with S1's instructions. LPA also interviewed other residents and according to resident #2 (R2), S1 has yelled at R2 as well. In addition, LPA interviewed S1 who acknowledged of yelling back at residents when residents became repeatedly disrespectful to S1. Furthermore, LPA interviewed the former facility manager who also acknowledged S1's behavior and stated that the facility has been addressing S1's inappropriate behavior both in verbal and in written. After the investigation, the above allegation is deemed to be substantiated. Substantiated Regarding to the allegation of staff do not treat resident with dignity and respect, in addition to staff yelled at R1, R1 stated that when R1 was hospitalized, facility staff moved R1's belongings without R1's presence and permission. As part of the investigation, LPA interviewed S1 who acknowledged that staff moved and cleaned R1's belongings while R1 was out of the facility as R1's room was too cluttered. During LPA's 10-day complaint inspection, LPA observed R1's personal belongings were displaced from R1's room without R1's consent. After the investigation, this allegation is substantiated. Based on interviews and observations during the course of the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. This report is discussed with Administrator and a copy of is provided including the Appeal Rights. During the 10-day complaint visit, LPA observed R1 was lying on a hospital bed with a special pressure relieving mattress, and 2 half bedrails up by the head of the hospital bed. Based on the documents provided, LPA observed the dates and times when R1 refused to be turned and repositioned by staff. Base on record review, observations, and interviews during the course of investigation, this allegation is unsubstantiated as the facility provided actions to prevent R1 from developing pressure injuries including making referral to a home health agency for wound management and obtaining a special mattress for relieving pressure but due to R1's health condition, R1 developed pressure ulcer and it was healed. Although the above allegation is deemed to be unsubstantiated, the facility was not able to provide a written order from the physician for the half bedrails, therefore, this finding will be cited on a LIC 809 and LIC809D under Postural Supports. Regarding to resident developed a rash while in care, the reporting party stated that R1 developed a rash due to the plastic ties from the adult brief were too tight around R1's stomach. As part of the investigation, LPA interviewed R1 who did not express any concerns regarding to staff placing the adult brief too tight and R1 was not aware of a rash developed around R1's stomach. LPA interviewed staff who stated that they knew not to place the audit brief too tight on R1 and they left one plastic tie untied. LPA observed R1 and validated this practice. Based on interviews and observations during the course of the investigation, this allegation is deemed to be unsubstantiated. Regarding to resident is not properly bathed while in care, the reporting party stated that facility staff often do not rinse the soap off of R1 thoroughly after a bed bath. As part of the investigation, LPA interviewed the former facility manager who denied the allegation and stated that facility has recently switched from regular soap to a no-rinse bathing wipes for bed baths. Therefore, there was no rinse-off needed and it would be normal for a resident to feel the mild cleaning solution that is contained on the wipes after the bed bath. LPA interviewed R1 who stated that the facility staff was providing unsatisfactory bed baths as staff did not rinse R1 thoroughly as R1 continued to have the slippery sensation on the skin after the bed baths. LPA interviewed resident #2 (R2) and resident #3 (R3) who also received bed baths from staff and both of them reported that they were satisfied with the bed baths that they were provided. Based on interviews and observations, this allegation is deemed to be unsubstantiated. Facility staff has explained to R1 of the no-rinse bathing wipes and agreed to go back to soap if R1 prefers. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is discussed and reviewed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Oct 20, 2022 · control 14-AS-20220914194750

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(2) · Plan of correction due date: Oct 24, 2022

87413 Personnel - Operations (a) In each facility:(2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. The requirement is not met as evidenced by: staff #1 (S1) yelled at residents during care and supervision which poses an immediate health risks to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: The administrator and the licensee will develop a plan of correction to ensure residents are not being verbally abused during care and supervision. The plan needs to illustrate the steps that the facility will take to monitor that this behavior does not happen again. In addition, the administrator will provide in-services to staff to prevent abuse from happening again. The facility will submit a copy of the plan and in-service sign-in record to CCL by the plan of correction due date 10/24/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Nov 3, 2022

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,...(1) To have a reasonable level of personal privacy in accommodations... This requirement is not met as evidenced by: The facility moved and displaced resident #1's personal belongings from R1's room without R1's presence, and consent which poses a potential health risks for resident in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: The administrator will provide in-service to staff - Rights of Residents and Privacy and provide a copy of the sign-in record to CCL by 11/3/2022.

Type of visit: Case Management - Other

On 10/20/2022, Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220914194759. LPA met with the administrator and explained the purpose of the visit. During the course of the investigation, the allegation of resident sustained pressure injuries while in care was unsubstantiated, however, LPA observed resident #1 (R1) and resident #2 (R2) were in a hospital bed with 2 half bed rails up by the head of the bed and according to staff #1 (S1), this device is used to assist R1 and R2's mobility in bed. However, the facility was not able to provide a written physician's order for such device for R1 and R2. Based on documents provided, the bed rails for R1 and R2 were not addressed in the appraisal /needs and service plans. Furthermore, the appraisal / needs and service plans for R1 and R2 were not signed by R1 and R2 and/or their responsible party(s) indicating that they reviewed and agreed with the service plans. In addition, during the course of the complaint investigation, R1 expressed satisfaction with the services that was provided by the home health visiting nurse, however, R1 was pressured by facility staff to discontinue the services by this visiting nurse as R1 was told by the facility staff that the visiting nurse did not properly follow through with R1's physician on R1's medication but R1 disagreed. Based on complaint investigation, deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator. A copy of this report and the Appeal Rights are provided.the state’s words, verbatim · CDSS document, Oct 20, 2022

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.80(a) · Plan of correction due date: Oct 24, 2022

§1569.80 Care and services decision making; meeting; written record a) A resident of a residential care facility for the elderly, or the resident's representative, or both, shall have the right to participate in decision making regarding the care and services to be provided to the resident. This requirement is not met as evidenced by: R1 is satisfied with services that was provided by the home health visiting nurse. However the facility pressured R1 discontinuing the services from this visting nurse which posed an immediately health risks to resident in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: The administrator will meet with R1 and if R1 decides to resume the services from this visiting nurse, facility will assist and coordinate with R1 and R1's provider to do so. The administrator will provide in-services to staff on this regulation. The administrator will inform CCL in writing of R1's decision and will submit a copy of the in-service record to CCL by the plan of correction due date 10/24/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Nov 3, 2022

87463 Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement is not met as evidenced by: during the 10-day initial complaint visit, LPA observed R1 and R2 have half bed rails up by the head of their beds, however, the need of utilzing this device was not reflected in their appraisal needs which poses a potential health risk to residents in carethe state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: The administrator will review all residents appraisal /needs and services plans including and not limiting to R1 and R2 to ensure they are updated and accurate to the care that is provided to each resident. The administrator will submit a copy of all the updated appraisal/ needs and services plan to CCL by the plan of correction due date of 11/3/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Nov 3, 2022

87608 Postural Supports (a) Based on the individual's preadmission appraisal, Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support... This requirement is not met as evidence by: R1 and R2 have half bed rails by the head of the bed and there was no written order from their physician which poses a potential health risks to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: The administrator will review the regulation pertaining to Postural Supports and provide in-services to facility staff. The administrator and/or designee will obtain a written physician's order for R1 and R2's half bed rails. The administrator and/or designee will conduct an evaluation of all the resident's beds for postural supports and if one is being used, the facility will obtain a physician's order indicating the need for the device that is being used. The administrator will provide a copy of the in-service and a copy of all the physician's order obtained to CCL by the plan of correction due date 11/3/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(c)(3) · Plan of correction due date: Nov 3, 2022

87457 Pre-Admission Appraisal - General(c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed..(3) The prospective resident, or his/her responsible person,...shall be involved in the development of the appraisal. This requirement is not met as evidenced by R1 and R2's appraisal needs/service plans were not signed indicating it's reviewed and agreed by the residents and/or their responsible parties which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: The administrator and/or designee will review the appraisal needs/plans of R1, R2 and all other residents to ensure it has been reviewed, signed and agreed by the residents and/or responsible parties. The administrator will develop a plan to ensure this task is completed moving forward. The administrator will provide a copy of all the completed residents appraisals and service plans and a copy of the above plan to CCL by the plan of correction due date 11/3/2022.

Type of visit: Case Management - Other

On 10/20/2022 Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220930104518. LPA met with the administrator and explained the purpose of the visit. During the course of the investigation, the allegations of staff are not following resident's Admissions Agreement and Resident's Representative did not receive a copy of the Admissions Agreement, the facility was not able to provide R1's admission agreement to LPA for review as staff #1 (S1) stated that R1's admission agreement is maintained with the former facility manager and not at the facility. Based on the complaint investigation, the facility did not ensure R1's current record is maintained in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator. A copy of this report and the Appeal Rights are provided.the state’s words, verbatim · CDSS document, Oct 20, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(b)(15) · Plan of correction due date: Nov 3, 2022

87506 Resident Records(a)The licensee shall ensure...a current record is maintained for each resident in the facility.. readily available to facility staff and to licensing agency staff..(b) Each resident’s record shall contain.. (15)The admission agreement.. This requirement is not met as evidenced by: the facility did not have resident #1 (R1)'s admission agreement in the facility which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: The administrator and/or the licensee will review the regulation and submit a written statement of acknowledgment after the review. The administrator will provide an in-service to staff on the regulation. The administrator will submit the above plan of correction to CCL by the plan of correction due date 11/3/2022.

Allegation investigated: Facility floors are not being cleaned in an odorless cleaner

On 12/27/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day initial inspection. LPA Han met with the House Manager, Gem Arceo and explained the purpose of the visit. Regarding to the facility floors are not being cleaned in an odorless cleaner, the reporting party stated that the facility used a floor cleaner that contains bleach which was toxic to smell and the facility stopped using it in the reporting party's room after the reporting parting spoke to the facility staff. However, the facility continued to use it thought-out the facility which created a strong, and pungent smell. During the investigation, LPA Han toured the upper and the lower level of the facility. LPA Han did not observe any strong odor in upper level. However, LPA observed a strong odor in the lower level hallway and in the bathrooms. In addition, there was no air circulation devices to minimize the odor. According to the facility staff, the odor was from the cleaning solution(s) that the facility used to clean the floor and the bathrooms downstairs and the staff who was responsible to perform these tasks did not dilute the solution with an appropriate amount of water which created the strong odor. Substantiated LPA Han interviewed the residents regarding to the smell from the cleaning solution(s) and some of them stated that they noticed the smell but it did not bother them but one of them stated the smell was there on a daily basis when the facility cleaned the floor and it was strong and unpleasant. Based on interviews and observation during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the House Manager, and Appeal Rights provided This report is discussed and reviewed with the house manager. a copy is provided.the state’s words, verbatim · CDSS document, Dec 27, 2021 · control 14-AS-20211220125424

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Jan 10, 2022

PERSONAL RIGHTS OF RESIDENT IN ALL FACILITIES:(a) Residents in all residential care facilities..shall have following personal rights:(2)To be accorded... healthful and comfortable accommodations..and equipment. This requirement was not met as evidenced by: LPA Han observed a strong, and pungent smell in the lower level which was caused by the cleaning solution and according the resident, the smell was strong and unpleasant which posed potential health and safety risks to resident in care.the state’s words, verbatim · CDSS document, Dec 27, 2021

Plan of correction: The Administrator and/or designee will reeducate the staff regarding the proper mixture of the water and the cleaning solution . The Administrator and/or designee will monitor the smell from the solution. If the smell contines to be pungent and unpleansant to the resident(s), the facility shall replace the items to odorless solutions. The Administrator and/or designee will place devices in the lower level of the facility to create a better air circulation. The Administrator will submit proof(s) to the Regional Office of the education, all the cleaning solutions that will be used after the assessment and the picture(s) of the device(s) that will be used to increase the air circulation by the plan of correction due date 1/10/2022.