The Commons on Thornton

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding incident report received dated 09/11/2023 . LPA explained purpose of visit to the administrator. LPA reviewed incidents reports and facilities theft policy, the facility provides a locking cabinet in residents room to detour theft. All incidents were reported on time and to the correct departments. Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 11, 2023

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding incident report received dated 07/07/2023 . LPA explained purpose of visit to the administrator. LPA reviewed residents files and the needs and services plans were updated as needed. Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 20, 2023

Allegation investigated: Staff is mishandling the residents medication Staff behavior poses as a risk to the residents

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver findings for the allegations listed above. LPA was greeted by Executive Director and explained the reason for the visit. Based on information gathered from R1 and R2'S files, doctors reports and interviews R1 and R2 are both able to administer their own medication. Due to the information gathered LPA finds allegation to be UNFOUNDED. The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. copy of report given. Unfoundedthe state’s words, verbatim · CDSS document, Jun 14, 2023 · control 27-AS-20230519102450

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit stemming from a complaint (27-AS-20230215120903). LPA was greeted by Executive Director and explained the reason for the visit. During the course of the investigation of the above noted complaint it was discovered that reports of the thefts were reported to the ombudsmen's office and was verbally reported to LPA Lewis and Johnson but was not submitted in writing to the department. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, Deficiencies are being cited during this meeting. See 9099D page. Exit interview conducted. copy of report given.the state’s words, verbatim · CDSS document, Jun 14, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(d) · Plan of correction due date: Jun 15, 2023

D)Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; This regulation was not met as evidence by: The licensee did not ensure that the facility provided a written report to licensing for the mutaple thefts at the facility. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jun 14, 2023

Plan of correction: Licensee/Administrator shall submit a Statement Of Understanding regarding the reporting requirements outlined in regulations by POC date via email Statement shall include the requirements as outlined in the regulation identified in this citation. POC already completed. Sent to LPA via email.

Allegation investigated: Staff are not safe guarding resident's personal items.

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced deliver findings for the allegation listed above. LPA was greeted by Executive Director and explained the reason for the visit. Allegation: Staff are not safe guarding resident's personal items. After reviewing docutmatuion and interviews with residents and staff regarding the allegation LPA Lewis finds the complaint to be unsubstantiated. The facility was able to provide detailed information and show written policy about what is to be done in the even there was a theft at the facility. LPA finds the facility followed the policy in the incidents of theft. Therefore, this complaint is UNSUBSTANTIATED. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted. copy of report given. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 17, 2023 · control 27-AS-20230215120903

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(d) · Plan of correction due date: May 29, 2023

D)Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; This regulation was not met as evidence by: The licensee did not ensure that the facility provided a written report to licensing for the mutaple thefts at the facility. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Licensee/Administrator shall submit a Statement Of Understanding regarding the reporting requirements outlined in regulations by POC date via email

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit for an indent that occurred on 05/08/2023. LPA was greeted by Executive Director and explained the reason for the visit. LPA reviewed R1'S file and took copies of the Physician's Report (602), hospital discharge orders email to R1's Physician, fax to the Physician and the needs and service plan. R1 bought the medication on a shopping trip with facility staff (S1). the medication (Advil) bottle had a total of forty (40) pills when staff found R1 there was 28 of 40 pills left in the bottle R1 was holding 4 pills in their hand. The 4 pills are included in the 28. R1 told facility staff that they took 6 pills two (2) days later. Staff can't conform when pills were taken. Per R1's LPA interviewed Executive Director about the incident. It was conformed during interview that the medication was bought on a shopping trip with facility staff. Per California Code of Regulations, Title 22 deficiencies were observed or cited during today's case management inspection. See 809D page. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, May 17, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(c) · Plan of correction due date: May 18, 2023

Basic Services (c) "Care and supervision" means the facility assumes responsibility for, or provides... assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes ...personal care. This requirement was not met as evidenced by: based on interview with Executive Director facility staff took R1 on a shopping trip in which they witnessed them buy the medication. This poses an immediate health and safety risk to resident.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Licensee to schedule and conduct an in-service training on basic services, and care and supervision. Copy of training materials and list of attendees due to CCL. Training to be scheduled by 0518/2023.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by Executive Director. LPA explained the purpose of the visit to the Executive Director. LPA Lewis inspected the physical plant including but not limited to the kitchen and food supply, dining room, several resident bedrooms, resident bathrooms, laundry area, living area, activities area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. The Memory Care area was also inspected. Facility is a 110 bed facility with a current census of 88. There are 64 residents in assisted living and 24 in the memory area. The entrance area and hallways have COVID precautions in place including social distancing noted. Toxins and medications noted to be locked to residents in care. Hot water temperature was measured at 108 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. 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 adequate food supply of 7 days non-perishables and 2-days perishables in place supplied by Sysco Foods. Resident rooms were sanitary and had the required furniture. LPA observed, fire extinguishers inspected on 3/7/2023 and current, smoke and carbon monoxide detectors. The first aid kit was found in compliance. Sprinkler and conveyance systems all in compliance. Due to time restraints LPA will return at a later date to complete the annual inspection.the state’s words, verbatim · CDSS document, May 17, 2023

Type of visit: Case Management - Incident

On 04/13/23 Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility for the purpose of conducting a case management incident inspection regarding incident report received dated 04/10/23. LPA explained purpose of visit to the administrator. LPA reviewed R1'S file and the needs and services plan was updated on 4-11-2023. Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 13, 2023

Type of visit: Case Management - Incident

On 01/30/23 at 09:45 am Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility for the purpose of conducting a case management incident inspection regarding incident report received dated 01/27/23. LPA explained purpose of visit to the administrator. LPA reviewed R1'S file and took copies of the Physician's Report (602), COVID testing and charting notes. LPA Lewis requested administrator contact family and obtain a copy of the death certificate when available and email to LPA Lewis. Kesha.Lewis@dss.ca.gov R1 tested positive on 02/16/2022 for COVID-19 but not since then. Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection. An exit interview was conducted and a copy of this report will be emailed to administrator as LPA'S printer is not working at this time.the state’s words, verbatim · CDSS document, Jan 30, 2023

Type of visit: Case Management - Incident

On 12/12/22 at 10:00 am Licensing Program Analysts (LPA'S) Kesha Lewis and Albert Johnson arrived at the facility for the purpose of conducting a case management incident inspection regarding incident reports received dated 11/02/22, 11/15/22, 11/15/22,/11,23/22. LPA explained purpose of visit to the administrator. Based on records reviewed, R1 is marked as not a fall risk but has had multiple falls before the assessment was done on 11/22/2022, Falls- 11/15/22, 11/15/22,11/16/22, and a fall after the assessment was done on 11/29/22 (copies taken of fall reports). The responsible party for R1 is looking for a higher level of care. (copy taken of physician visit form). Falls are addressed in the needs and services plan. The facility has a loss prevention program in place (copy taken). Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 12, 2022

Type of visit: Required - 1 Year

PA Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by Executive Director Marie Arbios and LPA explained the purpose of the visit and Ms. Arbios accompanied LPA on the facility inspection. LPA Jacobs inspected the physical plant including but not limited to the kitchen and food supply, dining room, several resident bedrooms, resident bathrooms, laundry area, living area, activities area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. The Memory Care area was also inspected. Facility is a 110 bed facility with a current census of 102. There are 76 residents in assisted living and 26 in the memory area. The entrance area and hallways have COVID precautions in place including social distancing noted. Toxins and medications noted to be locked to residents in care. The facility submitted a LIC 808 mitigation plan, which was approved. The facility is working on their infection control plan. 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 supplied by Sysco Foods. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and are in good repair. Fire extinguishers were serviced on March of 2022 and are in compliance. The facility has operable carbon monoxide and detectors and the smoke detectors were tested are also operational. The facility has a built in sprinkler system alarm system that was tested in April 2022 and is operable. Facility has an emergency food and water supply in a separate storage area in kitchen. Water temperature was tested between 110 and 114 in several residents rooms and is within the required range of 105 to 120 degrees F. First Aid kit is on-site and was checked. All staff on-site have current fingerprint clearances. Administrator's Certification for Marie Arbios is current. LPA requested the following documents to be updated: LIC 500 and LIC 309 have been received in March 2022. No deficiencies were observed during this visit Exit interview was held and a report was given to Ms. Arbiosthe state’s words, verbatim · CDSS document, May 12, 2022

Type of visit: Case Management - Other

Licensing Program Analyst Bruce Jacobs conducted a case management visit in regards to a reported change in the Executive Director Facility Administrator position. LPA met with new Facility Administrator Marie Arbios and requested the following documentation due to the Department by close of business on March 16th, 20022. For Administrator changes, the Regional Office is requesting the following: * A letter from the licensee and/or Board appointing the individual as the Administrator . * LIC 200 signed by the licensee or designee. * LIC 500 to indicate the days/hours the administrator is in the facility. A copy of the Administrator Certification and LIC 308 and LIC 501 has been received by LPA. It was reported that appointed individual is fingerprinted and associated to the facility, to be verified by LPA, No deficiencies were identified on this visit and report provided to Executive Director Marie Arbios.the state’s words, verbatim · CDSS document, Mar 8, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst Bruce Jacobs conducted a case management visit in regards to two incident reports submitted to the Department and received by LPA on 12/14/21. LPA met with Executive Driector Carol Miller and discussed the reports and and the residents. Both reports document that there are two residents with Stage 2 pressure injuries, one on hospice and the other in Assisted Living. Both residents are receiving Home Health wound care services. LPA agreed to provide facility with the Hospice Guide. No deficiencies were identified on this visit and report provided to the Executive Director.the state’s words, verbatim · CDSS document, Dec 15, 2021

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Bruce Jacobs, Licensing Program Managers Liza King and Stephanie Doub, Regional Manager Krystall Moore and Health Care Associated Infections (HAI) representative Hosniyeh Bagheri, Infection Preventionist, CDPH conducted an office visit via teams on 10/14/21 at 4:00pm with Commons on Thornton Administrator Carol Miller to discuss the recommendations provided by HAI following the onsite visit on 09/22/21. This Health and Safety visit is to ensure the facility is following the appropriate infection control protocols. HAI Summary and Recommendations Reviewed: · Facility was not aware of the response testing protocol. Response testing should be initiated as soon as one or more positive staff/resident identified in the facility and should be continued up to 14 days after the last positive case/s is identified. There should be at least 2 consecutive negative results for all staff and residents on the weekly basis testing and 14 days passed from the last positive. Please check with DSS and LPH for more information in this regard. · Consider to quarantine all negative residents until the termination of the outbreak and use appropriate PPE accordingly · Limit the visitation, group activities and communal dining as per your mitigation plan during the outbreak. · Consider to cohort staff for positive residents and non-positive ( Exposed residents) if possible Continued... Page 1 of 3 · Make ABHR dispensers available at the POC, they can be installed outside of the resident’s rooms, if there should be a risk for consumption of ABHRs by residents then they can be placed in isolation carts. Staff can also be provided with the small pocket size bottles. It is important for the staff to perform HH before and after care regardless of donning gloves. · It is recommended to do active screening for all staff and visitors upon reporting to their shift including verifying vaccination status from all visitors and staff. · Refer to PIN 21-40, vaccination status verification and testing requirement for visitors for further information. · Exposed residents (Covid-19 negative) are not quarantined and staff do not put on full PPE for the contact with these residents. It is recommended to consider the whole unit exposed and place the residents under quarantine until 14 days of the last positive staff and /or resident in the unit. Full PPE including gown and gloves is necessary when staff take care for these resident · There is an isolation sign on the resident’s door but the instruction of the infection control practices such as hand hygiene and use of PPE are not included on the sign. It is recommended to have these information on the sign displayed on isolation room to remind and educate staff on necessary infection control practices. Sample sign is attached to the email of this report that facility may consider using them. · Facility uses premix disinfectant from echo lab for environmental cleaning and disinfection from. Consider to review cleaning/ disinfection products from EPA List N that has the list of disinfectant agents against Covid-19 including the information regarding contact time. Assure if staff is aware of the disinfectant products contact time. Label the containers with a large print with the name of the product, and contact time and expiration date if applicable for easy reference for staff who uses the products. Removed trash bags should be directly disposed in dumper, do not leave them on the floor to avoid the surfaces and floor contamination. Continued Page 2 of 3 · Make sure all high touch surfaces are cleaned and disinfected regularly. Provide staff with the list of high-touch surfaces and avoid cross contamination throughout the process of cleaning. The educational flipcharts are attached to the email of this report to use for staff education. · Use microfiber cleaning cloths versus the cotton towels for environmental cleaning/ disinfection. Microfiber comprised of densely constructed synthetic strands and cleans 50% better than comparable cotton · Don gloves before the care or task after performing HH and remove immediately after completing the task. Instruct staff to not carry gloves in their pocket to avoid contamination of clean gloves · Establish a mechanism for identifying clean vs contaminated equipment such as bagging, tagging, signage or designated space to assure equipment are only used after they are cleaned and disinfected · Continue N95 respirator fit testing for all staff prioritizing the clinical staff. Educate staff to perform seal check every time they put on respirator. Check this video at CDC for further information Donning (Putting on) and Doffing (Taking off) and User Seal Checks Video · Make sure that N95 respirators are used without combining with any other masks. · Consider to use adherence monitoring tools for infection control practices such as Hand hygiene, environmental cleaning, PPE donning/doffing, and Fluorescent marker utilization to monitor environmental cleaning. You can find CDPH Adherence Monitoring Tools at CDPH website · As the mitigation strategies are difficult to implement in the memory care setting, refer to “COVID-19 and Memory Care Units Reference Sheet” attached to the email for some information about managing Memory Care residents. Facility Evaluation Report provided to the Facility Administrator. Signed by Debbie Warren.the state’s words, verbatim · CDSS document, Oct 14, 2021

Type of visit: Case Management - COVID-19

LPA Bruce Jacobs met CDPH HAI Hosniyeh Bagheri arrived at the facility for infection control training and mitigation. LPA and HAI met with Administrator Carol Miller. The census was 100, with 9 residents on hospice. Hosniyah provided information and instruction on isolating testing and infection control practices. Questions answered on the isolation of residents, testing and staffing concerns.. Also discussed were visitation requirement, Dining and activities are closed until the facility is cleared. A tour of the facility was conducted. LPA observed physical plant was clean and in good repair. There is an exterior hand washing station where all staff and visitors enter the facility. PPE and the visitor's log were observed. Staff screen at the beginning and end of the shift. Soap, sanitizer, and paper towels were available at kitchen hand washing sink. Meals were served in rooms at this time. PPE and sanitizer was available throughout the facility. There is an entire room dedicated to PPE storage and regularly tracked inventory. Staff restroom was stocked with soap, sanitizer, paper towels. Employees are breaking in lobby and activities director is responsible to clean the tables in-between use. All residents live in individual apartments with restroom, kitchen, and living room. Exit interview conducted and a copy of the reported provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 22, 2021