Arlyn's Guest Home

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Albert Johnson arrived at this facility unannounced to conduct a case management visit. LPA met with Staff explained the purpose of the visit. R1 was given a 30 day notice for failing to follow house rules and not taking medication. R1's primary care physician was notified. R1 also is being treated by mental health and is currently at St. Joseph's hospital for medication management. The facility also reported that R1 broke the television and the police had to come out and assist in redirecting R1. R1 would not calm down and was taken by the police to behavioral health and then transferred to St. Joseph's hospital. R1 will not be coming back to the facility, R1 needs a higher level of care. No deficiencies were cited as a result of this visit. An exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 30, 2023

Type of visit: POC

LPA Johnson arrived unannounced to clear the POC's from visits dated 06/20/2023 and 6/23/23. The following deficiencies, initially cited during those visits have been cleared:the state’s words, verbatim · CDSS document, Jul 12, 2023

Type of visit: Case Management - Deficiencies

LPA Albert Johnson made an unannounced visit on this date to complete a health and safety check and to follow-up on Case management visit on 6/20/2023. LPA was informed that the facility was currently operating without an Administrator. LPA confirmed that the facility has a Certified Administrator, however that Administrator is out of town until the 29th of June 2023. The .department has requested: -staff schedule(LIC 500, LIC 308) -land line phone number 209 851 8849 and alternate 209 954 2213 Cell phone -staff training, first aid is current with all staff -test smoke detectors to ensure they are in good working condition (two of nine smoke detectors not working.) The facility has requested an extension to submit additional plans of correction for the visit on 6/20/2023. Extension was granted until 6/26/2023. Deficiencies cited at this time for the smoke detectors. Exit interview conductedthe state’s words, verbatim · CDSS document, Jun 23, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202 · Plan of correction due date: Jun 24, 2023

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by testing two detector not working in the main hallway. This is an immediate safety risk.the state’s words, verbatim · CDSS document, Jun 23, 2023

Plan of correction: Administrator shall replace battery in smoke detector by POC date and submit a statement of compliance via email to CCL.

Type of visit: Case Management - Other

LPM Liza King arrived at the facility and met with caregiver (CG) Bella Ramos who is a livein caregiver. The licenssee has been out of the country since the beginning of May. This CG reports that there normal schedule is 4:30 pm to 6am and they work alone during this time period 7 days a week for the past few weeks. CG has been employed for about a month. A check of Guardian shows CG is fingerprint cleared but not associated to the facility. 2 additional CGs arrived at the facility at 7:20 and are fingerprint cleared and associated. A tour of the facility revealed there are 6 residents whom reside at the facility one of which was sent to the ER earlier in the day. 2 residents require assistance w transfers, several residents appear to be confused, one resident is spanish speaking. CG has no access to personnel files or resident files, in the event of an emergency the CG would contact the licensees husband for assistance. The CG has no access to responsible parties numbers. A facility sketch was not reviewed or present, staff bedroom was observed to be unlocked with medications present (right side of hall door 2), this door cannot be locked, there is no room for the medications to be locked with resident medications and no other locked area per LPM observations and reported by CGs. Area undersink lock broken and all chemicals accessible. Garage door is unlocked chemicals accessible in unlocked cabinets, some locks are broken others are not but all are unlocked. CG does not have key. The last door right side of hall labeled "office" unlocked and used as a storage area, no toxins observed, fall hazard present - room has plastic bags and boxes piled up. Kitchen was observed to be clean and resident medications were locked in cabinet. Refrigerator had a lock which was removed during visit. The following citations were issued per Title 22 regulations. The RO reserves the right to return at a later date to issue additional citations based on the information provided above incl the absense of the Admin / Licensee from the country without notification to the department. The report was reviewed with CG 1, 2 and 3. The report and appeals rights will be provided via email on 6/21/2023 A LIC500 shall be submitted to the department by end of day 06/22/23.the state’s words, verbatim · CDSS document, Jun 20, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jun 22, 2023

Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This regulations was not met as evidenced by: lpm observed medications that were accessible in the staff room, cleaning supplies were unlocked under the sink and in unlocked cabinets in the unlocked garagethe state’s words, verbatim · CDSS document, Jun 20, 2023

Plan of correction: The licensee will provide proof of locks repaired or relpaced on areas that store medications and chemicals to Albert.Johnson@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(C)(4)(a) · Plan of correction due date: Jun 22, 2023

Care of Persons with Dementia (A) In addition to requirements a facility with fewer than 16 residents shall have at least one night staff person awake and on duty ... This regulation was not met as evidenced by: According to staff interview there is one CG present in the facilily from 430 pm to 6am whom sleeps during sleeping hours.the state’s words, verbatim · CDSS document, Jun 20, 2023

Plan of correction: The licessee will submit a Plan of correction by 06/22/23 to Albert.Johnson@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468.1(a)(3) · Plan of correction due date: Jun 22, 2023

Personal Rights: ..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: .(3) To be free from...interfering with daily living functions such as eating, sleeping, or elimination. This was not met as evidenced by: The LPM observed a chain and lock on the refridgerator.the state’s words, verbatim · CDSS document, Jun 20, 2023

Plan of correction: The lock was removed during the visit. The licensee will provide a statement to the LPA Albert.Johnson@dss.ca.gov that this regulation has been read, understood by themself and the staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(g)(2) · Plan of correction due date: Jun 22, 2023

Personnel Requirements: (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This was not met as evidenced by: LPM reviewed the facility roster at time of visit and CG1 had a criminal record clearance, however the staff was not associated to the facility and a transfer request had not been submitted.the state’s words, verbatim · CDSS document, Jun 20, 2023

Plan of correction: The licensee will submit to CCL Albert.Johnson@dss.ca.gov a transfer request on 06/22/23.

Type of visit: Case Management - Other

LPA Albert Johnson made an unannounced visit on this date to complete a health and safety check and to follow-up on personnel questions. LPA was informed that the facility was currently operating without an Administrator. LPA confirmed that the facility is operating with a Certified Administrator. The licensee inform LPA Johnson that she will be going out of town and that she will be securing a temporary Administrator while she is out of town. LPA is requesting that a staff schedule (LIC 500) be sent to CCL. This schedule should include the Administrator's hours for this facility. No deficiencies cited at this time. Exit interview conducted.the state’s words, verbatim · CDSS document, May 4, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson arrived at this facility unannounced to conduct an unannounced visit. LPA was met by Staff. LPA was unable to make contact with the land line that is on file and was unable to leave a message on the Licensee's cell phone. LPA was able to confirm that the facility has a land line (209) 851- 8849. LPA was able to address the need for the Licensee to have an active land line and to clear the voice mail of her cell phone. The facility currently has one resident on hospice and the request to have an additional wavier is not needed at this time. A review of (2) resident records was conducted. LPA 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. No citations issued today. An exit interview was conducted.the state’s words, verbatim · CDSS document, Mar 23, 2023

Type of visit: POC

LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual licensing inspection conducted on 1/09/2023. Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date. Facility was provided POC cleared letter.the state’s words, verbatim · CDSS document, Mar 7, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Administrator Arlyn Del La Cruz. LPA and Staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA and Staff measured the hot water temperature in residents bathroom at 118 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguisher and Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. medication logs. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 12/5/2022. Exit interview conducted and appeal rights giventhe state’s words, verbatim · CDSS document, Jan 9, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80075(k)(3) · Plan of correction due date: Jan 10, 2023

(3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. The facility conducted a fire drill on 2/5/2022. This does not met the requirement for this regulation while caring for a resident with Dementia.the state’s words, verbatim · CDSS document, Jan 9, 2023

Plan of correction: The licensee shall conduct a drill by the POC date odf 1/10/23. The facility will document this drill and keep a copy in the facility file for review.

Type of visit: POC

LPA Johnson arrived unannounced to clear the POC's from visit dated 01/04/2022. The following deficiencies, initially cited during a visit on 01/04/2022, have been cleared:the state’s words, verbatim · CDSS document, May 31, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Nieves and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications for each resident. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 resident and 2 staff files, including criminal record clearances. During the resident files review LPA observed that R1 had a fall on 1/2/2022 further investigation determined that R1 had a visit to the ER on 11/3/2021 for a foot injury, this was not reported to the department. The facility is also out of compliance with service plans for 3 of 6 files reviewed. Fire drill was completed on 6/24/2021. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. There is continued issues with deficiencies, therefore this facility will be referred to technically support. Exit interview conductedthe state’s words, verbatim · CDSS document, Jan 4, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jan 14, 2022

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above in (2) out of (2) residents diagnosed with dementia which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 4, 2022

Plan of correction: Licensee agrees to submit a plan of correction to LPA by 1/14/2022 on how R1 and R2's annual appraisal will be completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(c) · Plan of correction due date: Jan 14, 2022

The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, LPA observed Needs and Services Plan is outdated for R1 thru R3.the state’s words, verbatim · CDSS document, Jan 4, 2022

Plan of correction: The facility shall obtain a current Needs and Services Plan for R1 thru R3. Written certification stating administrator has read regulation 87463 along with copies of current Needs and Services Plan to be sent to CCLD by POC date

Allegation investigated: Staff refused to issue a refund.

LPA Albert Johnson made an unannounced visit to this facility today to deliver findings for the allegation listed above. Based on interviews conducted with placement agency and the facility. The department finds that the allegation to be unfounded. It was reported that R1 was sent to Arlyns Guest Home on and didn't like it. They (the family) took her out of the home immediately. They paid the placement agency $5193.54. This includes $2000.00 entrance fee and rent for the rest of May and June. However, the facility never recieved money for R1. As a result, the contract between R1's family and the placement agency will need to be addressed as a civil matter to recoup the funds paided. Continued Unfounded The facility did not start documentation for residency, R1 was out of the county and the Licensee was unable to do a pre-assessment, but was able to review the Physician's report and intended on completing the paper work when R1 arrived with family. The facility did they receive any of the monies paid to the placement agency and therefore is not responsible for repaying or refunding any fees paid to the placement agency. "This agency has investigated the complaint alleging the "Staff refused to issue a refund." The complaint is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis." An exit interview was conducted a copy of this report was providedthe state’s words, verbatim · CDSS document, Aug 27, 2021 · control 27-AS-20210721084730