O'Connor Woods Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA'S) Kesha Lewis and Maja Jenson arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA'S were met by Staff member and Assisted living manager joined 15 minutes later. LPA explained the purpose of the visit to staff and assisted living manager. LPA'S and staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. The facility is a two story building there are two buildings for the assisted living. Currently the facility has a current census of 85. There is entry door is leading to a common area living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care tool. Hot water temperature was measured at 120 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID -19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. LPA observed, fire extinguishers inspected on 03/2023 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA reviewed fifteen (15) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA reviewed eighteen (18) resident facility files six (6) files from memory care and twelve (12) from assisted living, COVID-19 Plan, and survey binder. All necessary documents were in place. Exit interview held and copy of report left at conclusion of visit.the state’s words, verbatim · CDSS document, Aug 14, 2023

Type of visit: Case Management - Deficiencies

On 8/214/23 Licensing Program Analysts (LPA'S) Kesha Lewis and Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies related to theft of a resident's funds. LPA Lewis met with staff and the human resources manager Art Garnica and explained the purpose of today's visit. On 08/10/23 the facility self reported the theft of a resident's funds by a staff member. The Administrator complied with all reporting requirements within the required time frame. The staff member was terminated. The Administrator notified law enforcement, APS and the Ombudsman.The Administrator also sent an LIC 624, LIC 9060 and completed an SOC 341A. LPA Lewis requested staff 1's (S1's) personnel file so that the Department can seek an exclusion on the responsible party. Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6. An exit interview was conducted and a copy of this report and appeal rights were given to the Administrator.the state’s words, verbatim · CDSS document, Aug 14, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Aug 15, 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 which have been entrusted to the licensee or facility staff. This requirement was not met as evidenced by: Based on the facility's self reporting, a staff member used a resident's credit card to place online orderss. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2023

Plan of correction: The Licensee immediately terminated the employee.The Licensee met with the family of the resident and explained all actions that have been taken. No other victims have been identified. No further Plan of Correction is required.

Type of visit: Case Management - Health Checks

On 1/4/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a health and safety check related to the 2023 Winter Storm. LPA Jensen met with Executive Director Penny Mallette and explained the purpose of today's visit. The facility is a Continuing Care Retirement Community with Independent Living, Assisted Living, Memory Care and Skilled Nursing. The Assisted Living unit currently has a census of 72 and the Memory Care Unit has a census of 26. A portion of the facility lost power on 12/31/22 and the power was restored in the late afternoon on 1/1/23. LPA Jensen observed a down tree on the grounds that appeared to have fallen away from the living units. The facility has generators that power the Assisted Living Unit/Memory Care and Skilled nursing units. These generators were in use for the outage in order to provide light and heat. The facility has a Public Announcement (PA) system that was used to communicate with residents. Portable generators are available for the Independent Living unit for use in the common areas. The units also have common gathering areas/recreation rooms that have gas fire places. Lanterns were used in the hallways of the Independent Living unit. All residents have emergency call pendents they can activate if they need assistance. The facility has not experienced staffing shortages and has contracts with staffing agencies if the need arises. The facility did loose a substantial food supply from the walk in refrigerator during the outage. The food supply that remained was supplemented by providing catered meals that included pizza and sandwiches until the food supply was replenished. LPA Jensen observed there to be 2 day supply of perishable food and a 7 day supply of non-perishable food on site. A large food order consisting mainly of proteins was delivered today and included steak, hamburgers, turkey, fish and frozen pastas. Continued on LIC 809C... While there was some fresh vegetables on hand, a large produce order is also scheduled to be delivered tomorrow. Food was delivered directly to resident rooms in Assisted Living during the outage and offered in the main dining hall for Independent Living. Residents in the independent living units had the option having their meal(s) delivered to their room upon request by using their pendents to call for staff. No residents were sent out to emergency medical care during the outage. No residents using oxygen were affected by the outage as power was lost in only a portion of the community. The Executive director has established an emergency response team consisting of staff that will be present and follow an action plan in the event this current storm causes more challenges. A resident forum was held yesterday (1/3/23) to discuss any concerns residents had related to this recent storm. The facility has placed an order for shipment of battery operated emergency lights for use in the stair wells of the independent living unit. The facility is also making arrangements for the lease of a refrigerated truck to have as a contingency plan in case power is lost again. The LIC 610E was reviewed and is in compliance. There are no health and safety concerns with the facility at this time. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 4, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted a Required 1 year Annual Inspection Visit. LPA also met with Executive Director and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 499 residents. The facility has 218 residents in Independent Living, 52 in Assisted Living and 27 currently in memory care. The facility has submitted and is following their Mitigation Plan and the focus of this evaluation was on infection control procedures and processes. Administrator Certificate - Dawn Shimel expires 1/23/2023. LPA toured the facility including but not limited to apartments, bathrooms, kitchen, dining room areas, common area and courtyards. All outdoor and indoor passageways observed were kept free of obstructions. A comfortable temperature throughout the facility is maintained at 74 degrees Fahrenheit. LPA observed lighting in apartments are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid floors. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Fire extinguishers were last serviced 3/24/2022 and are in compliance. A Fire Department inspection was completed on 12/17/20 and the facility passed the inspection. The inspection included tests on the alarms on egress doors, fire extinguishers, smoke detectors and alarm system. Emergency Disaster Plan was posted. Hot water temperature was measured at 114.2 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. LPA observed centrally stored medications locked inside the medication room. LPA with the assistance of facility Medication Technician reviewed and compared resident medication vs. resident medication logs. LPA reviewed 8 resident and 4 staff files, including criminal record clearances. All staff today are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. LPA was able to verify last documented fire drill was on 5/12/2022. LPA received updated copies of the following documents: LIC 308 Designation of Facility Responsibility and current copy of Liability Insurance. Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, No deficiencies were observed. Exit interview held with office coordinator and a report given at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Jul 22, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst Bruce Jacobs conducted an unannounced visit to the facility to review and discuss an incident report submitted to the Department by the facility. The report provided details involving the missing items of a resident. The report was discussed with the Administrator and LPA obtained additional details as well as the actions the facility has taken. The facility discovered the resident's items were missing, reported to Licensing, reported to the family who reported to Law Enforcement. The facility conducted an internal investigation including a search of the resident's room, interview of facility staff and health agency staff and cooperation with Law Enforcement. As of this date, the missing jewelry items have not been recovered and the facility is working with the family to resolve the issue. It was determined the facility was following their theft and loss plan. Exit interview conducted and no deficiencies were identified on this visit.the state’s words, verbatim · CDSS document, Mar 8, 2022

Type of visit: Case Management - COVID-19

On 09/30/21 at 9:00am Licensing Program Analyst (LPA) Kevin Gould and CDPH Infection Preventionist Kristy Trausch arrived at O'Conner Woods Assisted Living for the purpose of conducting a healthcare associated infections (HAI) inspection. LPA and HAI met with staff, Annette Montes and together conducted a tour of the facility. The facility is a multi-building facility providing assisted living, memory care, skilled nursing and independent living. There are two memory care buildings, 1 skilled nursing building, 1 independent living building and two assisted living buildings. LPA observed that screening for all visitors and residents is being conducted according to public health and CCLD recommendations. LPA observed all staff proving care in active COVID positive areas are wearing proper PPE including N95 masks and face shields. LPA observed plenty of hand sanitizing stations throughout the facility and buildings. Facility is documenting resident's temperatures daily. Facility is also utilizing other baseline measurements such a pulse oximeter to determine the need for additional care or hospitalization. CDPH recommends improvements to housekeeping procedures and surface disinfecting. CHPD recommended discontinued used of diluted bleach solutions as a disinfectant and to use a disinfectant with a wet surface time of three minutes or less. CDPH also recommended that disinfectant bottles be labeled with their contents. LPA observe an abundant supply of PPE including N95 masks, face shields, gowns and gloves. LPA observed PPE carts ready for deployment and a trash can with lid placed inside COVID positive isolation rooms. Facility is utilizing rapid antigen tests and PCR testing for COVID in the facility. LPA Gould observed the dining room in the independent living building and observed several large round tables with up to eight (8) place settings and chairs. LPA and CDPH recommended reducing capacity of the dining room by 50 percent with a maximum of 4 residents to the large round tables and no more than two residents to the smaller square tables. LPA was also informed that the church services are attended by all populations in the facility and mask wearing is required and they have not allowed singing at the chapel. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 30, 2021

Type of visit: Required - 1 Year

On 07/072021 at 9:10 AM, Licensing Program Analyst (LPA) Bruce Jacobs met with Facility Administrator Dawn Shimel to conduct a required 1-year annual inspection. LPA also met with Executive Director Penny Leal-Mallete and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 499 residents. The facility has 325 residents in Independent Living, 72 in Assisted Living and 28 currently in memory care. The facility has submitted and is following their Mitigation Plan and the focus of this evaluation was on infection control procedures and processes. LPA toured the facility including but not limited to apartments, bathrooms, kitchen, dining room areas, common area and courtyards. All outdoor and indoor passageways observed were kept free of obstructions. A comfortable temperature throughout the facility is maintained at 76 degrees Fahrenheit. LPA observed lighting in apartments are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid floors. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Fire extinguishers were last serviced in April 2021 and are in compliance. A Fire Department inspection was completed on 12/17/20 and the facility passed the inspection. The inspection included tests on the alarms on egress doors, fire extinguishers, smoke detectors and alarm system. Emergency Disaster Plan was posted., Updated copies of the following documents as needed were requested for facility file and are to be submitted to CCLD by 08/7/2021: LIC 308 Designation of Administrative Responsibility, LIC 309 Administrative Organization, LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan No deficiencies cited during inspection. Exit interview conducted with Administrator Dawn Shimelthe state’s words, verbatim · CDSS document, Jul 7, 2021

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.