Tarina of Stockton

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management visit today at the facility. The department received an incident report dated 10/7/2023. The LPA reviewed records, toured the facility and interviewed the Administrator about events related to medication errors and a resident moving out. The LPA reviewed resident records, staff records and staff training records. Medications and medication procedures were also reviewed. Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were cited during this visit. Advisories given. Exit interview held and appeal rights given.the state’s words, verbatim · CDSS document, Oct 16, 2023

Type of visit: Case Management - Incident

On 8/3/23 at approximately 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management related to an incident report for Resident 1 (R1). LPA Jensen met with Executive Director Gia Cocola and explained the purpose of today's visit. LPA Jensen reviewed 3 incident reports for R1. On 7/10/23, 7/15/23 and 7/17/23 R1 went to the emergency room for elevated blood sugar levels. LPA Jensen reviewed the LIC 602 which states that the resident is not able to administer his own medication or monitor his own glucose. LPA Jensen reviewed R1's need and service plan and it indicates that a licensed Practical/Vocational nurse will assist resident with glucose monitoring and insulin. LPA Jensen interviewed R1 who stated no one monitors his glucose and he administers his own insulin. LPA Jensen interviewed staff 1 (S1) and staff 2 (S2) and both confirmed that the resident administers his own insulin and is responsible for monitoring his own glucose. A deficiency is being cited from the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. The Executive Director stated the facility has an LVN on staff that has agreed to take over medication management for R1 effective immediately. An exit interview was conducted and a copy of this report, the LIC 811 and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 3, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Aug 4, 2023

Diabetes The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement was not met as evidenced by: Based on LPA Jensen's record review of the LIC 602, LIC 624's and needs and service plan as well as LPA Jensen's interviews with 2 staff members and 1 resident, the resident has not had medication administered by a skilled professional. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 3, 2023

Plan of correction: The Licensee agrees to have an appropriately skilled professional administer medication and conduct glucose monitoring for any resident that is unable to manage their own medication as specified on the LIC 602 effective immediately. No further plan of correction is required at this time.

Type of visit: Case Management - Deficiencies

On 6/22/23 at 2:30pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management for deficiencies in relation to incident reports received by the Department on 6/5/23. LPAs met with Executive Director Gia Cocola and explained the purpose of today's visit. Reporting Requirements On 6/5/23 six incident reports were faxed to the Regional Office for separate incidents that occurred on 5/3/23, 5/4/23, 5/14/23, 5/17/23, 5/22/23 and 5/25/23. Document Request On 6/5/23 Licensing Program Analyst Maja Jensen requested documents a due date of 6/8/23. An extension was granted through 6/12/23 and a further extension was granted through 6/13/23 and again through 6/14/23. LPA Jensen informed Executive Director Gia Cocola that only partial documents were received. Executive Director Gia Cocola showed LPA Jensen an email that was sent on 6/14/23 at 12:44pm. There were 4 consecutive emails that were sent back to back. LPA Jensen received 2 of 4 emails. During the course of the interview with Executive Director Gia Cocola, LPA Jensen was advised there was a short delay in sending the requested documentation as she needed to verify what documents could be released versus what documents are internal, as such technical assistance was provided related to the Inspection Authority of the Licensing Agency. Continued on LIC 809C... Continued from LIC 809 LPA Jensen requested and received the following resident records for R1: Admission Agreement Physician's report Pre-placement appraisal needs and service plan Emergency ID and contact information Charting Notes All incident Reports 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 was provided.the state’s words, verbatim · CDSS document, Jun 22, 2023

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

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... Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Based on the Department's receipt of 6 incident reports that were sent more than 7 days after occurrence. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jun 22, 2023

Plan of correction: The Licensee has implemented a new protocol for incident reporting wherein the Executive Director is immediately notified of the occurrence and an incident report is written up within 24 hours for review by upper management and their consulting group. No further plan of correction is required at this time.

Type of visit: Case Management - Other

On 4/6/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management related to the renovation project and HVAC replacement. LPA Jensen met with Executive Director Gia Cocola and explained the purpose of today's visit. The HVAC replacement project plans approved by the Department had an original estimated completion date of February 2022. The completion date for the project was delayed due an unforeseeable supply chain issue. The Licensee submitted an updated time line for the project in February of 2023. LPA Jensen spoke to Licensee by telephone who advised that the project has again been delayed as a result of a permit issue with the City of Stockton. The project is now expected to be completed in 4-6 months time. The Licensee advised LPA Jensen that resident care will not be impacted through completion of the project and has agreed to send a revised timeline to LPA Jensen by 4/20/23. In addition, it came to LPA Jensen's attention that there has been an change in Administrator. During the course of an interview with Executive Director, Gia Cocola, LPA Jensen was advised that the former Administrator exited her position approximately 3 weeks ago or around 3/9/23. The Executive Director also advised that she passed her Administrator's certification exam on 3/29/23 and is pending receipt of her certificate. LPA Jensen is requesting the following documentation by 4/13/23: -A letter from the licensee and/or board appointing the individual as the Administrator -An LIC 308 -Copy of current Administrator's certification -Any documentation that meets the education and/or experience requirements -An LIC 200 signed by the Licensee or designee -An LIC 500 to indicate the days and hours the Administrator is in the facility -An LIC 501 so we can determine if the Administrator meets the education/experience requirement Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 6, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Apr 13, 2023

Administrator Certification Requirements All facilities shall have a qualified and currently certified administrator. This requirement was not met based on: The facility's former Administrator having exited the position on or around 3/9/23 and the facility not having any evidence of a new Administrator of record. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 6, 2023

Plan of correction: Licensee agrees to submit the requested documentation for approval for a change in Administrator by Plan of Correction due date.

Allegation investigated: Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency were not properly implemented by facility staff. Reporting Requirement

On 2/13/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Executive Director Diane Wright and explained the purpose of today's visit. LPA Jensen interviewed the Executive Director and determined that the facility endured a power outage twice during the course of the 2022/2023 Winter Storms. The first outage lasted approximately 54 hours between 12/31/22 and 1/2/23 and the second ouitage lasted approximately 24 hours on or aorund January 8, 2023. During the course of the first outage some familes of residents or resonsible parties were not notified of the outage. During the second outage that occured on or around 1/8/23, the facility reached out to the listed emergency contact person for each resident. Community Care Licensing was not notified by facility staff that the power outage had occured during either incident but was made aware of the power outage by a concerned party. Continued on LIC 9099.... Substantiated The allegation of reporting requirement non-compliance is SUBSTANTIATED based on LPA Jensen's determination that the Community Care Licensing Department did not receive a timely written report of outage which qualifies as an incident that threatens the welfare, safety or health of any resident. A finding of substantiated means the preponderance of evidence standard has been met. LPA Jensen also reviewed the LIC 610E. The facility's approved Emergency Disaster Plan was last updated 1/4/23 and has been reviewed by 7 staff members including the Executive Director, Dietary Director, Resident Care Director, Resident Care Coordinator and Administrative staff. Under the LIC 610E Sheltering Place subsection specific to self reliance for periods of not less than 72 hours immediately following any emergency or disaster, including but not limited to , a short term or long term power failure it stipulates that in the event of a long term power outage "families will be notified to see if they want to bring the resident home, if needed we would relocate to sister community (Orangeburg). During the course of the first power outage, approximately 25% if the resident families were not contacted to be given the option of bringing the resident home. In addition, the LIC 610E indicates a plan to "contract with outside company to provide us with generator if power to be off for a few days. The Executive Director advised that while an outside vendor was contacted for potentially supplying a back up generator there was no 3rd party vendors available at the time due to such a large region being affected by outages. The Executive Director also advised that the facility's electrical panel is not adequately equipped for back up generator purposes however the faciloty is currently in the process of upgrading the electrical system. Based on LPA Jensen's review of the LIC 610E and interviews conducted the allegation of Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency were not properly implemented by facility staff is SUBSTANTIATED. A finding of substantiated means the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) and Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were given.the state’s words, verbatim · CDSS document, Feb 13, 2023 · control 27-AS-20230117141741

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 17, 2023

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...Any incident which threatens the welfare, safety or health of any resident...This requirement was not as evidenced by: Based on LPA Jensen's verification through interviews and review of submitted incident reports that the power outage was not reported to the Department as required. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2023

Plan of correction: Licensee will send an attestation that a plan has been implemented to notify the Department of any power outages or potential evacuations by Plan of Correction due date and will email the attestation to LPA Jensen.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(a)(7) · Plan of correction due date: Feb 17, 2023

Emergency Plans ...a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: ...Residents and their responsible parties shall be informed of the process for communicating during an emergency. This requirement was not met as evidenced by: Based on interviews conducted and a review of the LIC 610E the facility has a plan to notify families of emergency or disaster occurrences and this did not occur for every resident during the power outage from 12/31/23-1/2/23. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2023

Plan of correction: Licensee will send an attestation that a plan has been implemented to notify the resident's responsible paries of any power outages or potential evacuations by Plan of Correction due date and will email the attestation to LPA Jensen.

Type of visit: Required - 1 Year

On 12/2/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a one year annual inspection. LPA Jensen met with Executive Director Diane Wright and explained the purpose of today's visit. The facility is a two story building with a single designated entrance. There are infection control and COVID screening signs posted at the entrance and throughout the building. At the front hall reception desk there is an electronic sign in and screening system that generates a visitor tag. All staff were observed to be wearing masks. The facility maintains an adequate supply of PPE. The facility was observed to be sanitary and free of odor. LPA Jensen toured the kitchen, the dining hall, 2 activity rooms, the laundry rooms, main hall bathrooms, guest suites, medication room and grounds. The grounds were observed to be well maintained and all paths were free of obstruction. The window screens were all observed to be in good repair. The fire extinguishers were last serviced in September of 2022 and are in compliance. The kitchen was observed to be sanitary. There was a menu posted and lunch service was observed. The lunch served was consistent with the menu that was posted. The kitchen is separated from the dining hall and only employees have access to the kitchen. First aid kits were maintained and observed to be complete. Toxins and cleaning supplies were observed to be stored away from all food products. The ice machine was observed to be sanitary. LPA Jensen observed in excess of a 7 day supply of non-perishable food and a 2 day supply of non-perishable food. LPA Jensen toured 4 resident suites. The suites were observed to be adequately furnished and lit. 2 of 4 resident suites observed had portable heater units. 2 of 4 suites observed had an air conditioning unit in the window that was not properly sealed allowing for air flow from outside. Continued on LIC 809C.... The portable heaters do not have a mechanism to set the unit to specific temperature. LPA Jensen interviewed resident 1 (R1) and resident 2 (R2) with portable heaters in their room and R1 and R2 both indicated they have to constantly turn the heaters on and off in an attempt to adjust the temperature. 1 of 4 resident rooms had an HVAC system that had a broken fan creating a constant noise. LPA Jensen tested the call alert system in the room of R1 at 11:14am, LPA Jensen waited 20 minutes and there was no response by staff. LPA Jensen tested the call alert system in the room R3 at 10:34, LPA Jensen waited 12 minutes and there was no response by staff. Water temperature in resident suites was measured at 116 degrees which falls within the required regulatory range of 105-120 degrees. LPA Jensen observed the medication room to be organized and observed medications to be locked in med carts. The narcotics were locked separately. LPA Jensen conducted an audit of the narcotics in collaboration with Staff 1 (S1) and found the documentation and medication count to be in order. LPA Jensen observed an extensive activities program to be offered including but not limited to Holiday shopping, holiday dress up days, Christmas caroling, spiritual services, gift exchanges, shopping excursions, resident socials and service animal visitation dates. LPA Jensen reviewed 3 resident files and 2 staff files. The facility is in the process of conducting file audits and reorganizing staff and resident files to stream line and ensure all necessary documentation is easily accessible. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result result in civil penalties. An exit interview was conducted and a copy of this report and appeal rights was given.the state’s words, verbatim · CDSS document, Dec 2, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(1) · Plan of correction due date: Dec 9, 2022

87303 Maintenance and Operation ... (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement was not met as evidenced by: Based on an interview with the Executive Director there are currently 9 occupied units using portable heaters which does not allow for accurately setting a temperature in resident suites within the required range and creates a tripping and fire hazrd. This poses a potential risk to the health saftey and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2022

Plan of correction: The licensee agrees to install thermostats in the residents rooms and cease the use of the portable heaters, removed the window air conditioning units unless the resident requests otherwise and repair any broken HVAC units in resident suites.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i) · Plan of correction due date: Dec 3, 2022

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) 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. ... This requirement was not met as evidenced by: Based on LPA Jensen's test of 2 resident suite signal systems for which there was no response by staff in over ten minutes each. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2022

Plan of correction: Effective immediately the Executive Director will start reviewing signal notification reports and additional training has been conducted with staff during a shift change. Ongoing training will also be conducted. No further plan of correction is required at this time.

Type of visit: Case Management - Deficiencies

On 9/29/22 at approximately 2:15pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies related to theft of a resident's funds. LPA Jensen met with resident care coordinator Trish Velez and explained the purpose of today's visit. LPA Jensen also spoke to Administrator Diane Wright over the phone and explained the purpose of today's visit. On 9/16/22 the Administrator contacted LPA Jensen to notify her of a 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 Jensen 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, Sep 29, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Sep 30, 2022

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 check to deposit funds in to their own account. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2022

Plan of correction: The Licensee immediately terminated the employee. The Licensee also conducted staff training on mandated reporting. The Licensee met with the family of the resident and explained all actions that have been taken. The Licensee has made a safe available for residents to keep valuables in should they choose to do so. No other victims have been identified. No further Plan of Correction is required.

Type of visit: Case Management - Health Checks

On 09/10/2022, Licensing Program Analyst (LPA) Arielle Pascua arrived at the facility unannounced to conduct health and safety checks. LPA Pascua met with Medication Technician (MT), Shalini Peter and explained the purpose of today’s visit. Shortly after, LPA Pascua met with Medication Technician (MT), Jennifer Armendariz The purpose of this visit was to follow up on concerns regarding a high temperature in the facility. It was learned that the A/C has not been sufficiently cooling the facility. LPA Pascua interviewed the Facility Designated Administrator, Diane Wright on the phone. It was learned that the facility has been waiting on A/C units which have been backlogged for a couple of months. FDA, Wright stated that she will follow up on Monday to see if the A/C units have arrived. There are hydration tables on the first and second floor. The facility has purchased Portable Air Conditioners for every resident and have been installed in their respective rooms. Staff have been conducting wellness checks on residents every two hours or as needed. Additionally, the facility has 3 large fans at the end of each floor's hallways. There are two additional large fans in the front lobby, and dining area. Current temperature on the 1st floor hallways and resident rooms were measured to be 79-83 degrees. The temperature in the hallways and resident rooms on the upper level was measured to be between 78-83 degrees. Residents were observed to be comfortable and content with the temperature at this time. No deficiencies are being cited as a result of today's visit. An exit interview was conducted and a copy of this report was given to Medication Technician, Jennifer Armendarizthe state’s words, verbatim · CDSS document, Sep 10, 2022

Type of visit: Case Management - Health Checks

On 9/9/22 Licensing Program Analyst (Maja) Jensen arrived at the facility unannounced to conduct health and safety checks. LPA Jensen met Resident Care Director Jaenine Gaona and explained the purpose of today's visit. LPA Jensen arrived at the facility due to receiving a phone call related to concerns with the temperature in the facility. LPA Jensen toured the facility including kitchen, dining room, hallways and 4 resident rooms on the upper level. The temperature on the lower lever measured between 84 and 85 degrees. The temperature in the hallways and resident rooms on the upper level was measured at range between 87 degrees and 97 degrees which falls outside of the regulatory range of 68-85 degrees. A deficiency is being cited today from the California Code of Regulations, Title 22, Division 6. An exit interview was conducted and a copy of this report along with appeal rights was given to Jaenine Gaona.the state’s words, verbatim · CDSS document, Sep 9, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b)(2) · Plan of correction due date: Sep 10, 2022

The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not as evidenced by: Based on LPAs temperature readings of the upstairs hallway and 3 resident rooms that were above 85 degrees. This poses an immediate safety, health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2022

Plan of correction: Licensee made adjustments to a portable air conditioner unit in the room of a resident on the second floor during the course of the visit which lowered the temperature by 4 degrees within 30 minutes and the room continues to cool. Licensee agrees to add a hydration table to the hallway of the second floor by 7pm on 9/9/22. Maintenance will add two floor blowers to second floor and email or text temperature readings to LPA by 9/10/22. Staff will check on residents on the upper floor every two hours over the course of the 24 hours.

Type of visit: Case Management - Health Checks

On 8/15/22 at approximately 2:50pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a health and safety check and for follow up an informal meeting held on 7/18/22. LPA Jensen met with Administrator Diane Wright and explained the purpose of today's visit. Upon entering the facility LPA Jensen was greeted by front desk staff who assisted the LPA using in using an automated screening device that was recently installed. The screening device logged responses to all COVID-19 screening questions and also logged temperature taken. LPA Jensen toured the facility and the grounds, including but not limited dining room, hallways, resident rooms and activity rooms. LPA observed that all common areas were free of debris and hazardous items. The sliding door to next to the elevator located between the two wings of the facility was observed to be locked and signs were posted indicating there was no access to the roof. The laundry room was observed to be free of debris and toxins. The stair wells located on the end of each wing was observed to be free of obstruction or hazards. The grounds were observed to be maintained and free of obstruction. The facility is currently using portable air conditioning units with a separate air conditioning unit located in each resident room and a larger unit in the common areas. LPA Jensen interviewed two residents who confirmed their respective rooms are maintained at a comfortable temperature. No deficiencies are being cited as a result of today's visit. An exit interview was conducted and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Aug 15, 2022

Type of visit: Office

An Informal Conference was conducted today, 07/18/2022, via Microsoft Teams. The purpose of the Informal Conference was to discuss the facilities compliance with Title 22 Regulations as a result of deficiencies cited during complaint investigations and site visits on 1/24/22, 2/25/22, 3/30/22 and 4/15/22. Present at today's Informal Conference were: Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Maja Jensen and Licensees, Chris Coulter and Administrator Diane Wright. The informal conference process was explained during this meeting. The following issues were discussed during the informal conference: · COVID-19 Prevention · Storage of toxins and hazardous objects · Sufficient Staffing · Pest Infestation · Building and grounds maintenance. · Alert Notification System (Call Button System) Licensees stated they will do the following to achieve continued and substantial compliance: · Submit new LIC 500 personnel report with updated staff schedules by 7/25/22. Facility has current contracts with staffing agencies that it is not utilizing as they are fully staffed at this time · Adhere to COVID-19 screening procedures and Infection Control Plans. A calendar of training of staff and refresher courses will be submitted by 7/25/22 Continued on LIC 809C.... · Maintain regularly scheduled pest control services. Ecolab reports will be submitted via email by 7/25/22 · Maintain a clean, safe and sanitary building and grounds. An update to the HVAC plan will be submitted via email by 7/25/22 Licensees were offered an opportunity to participate in Department's Technical support Program. No deficiencies were cited from the California Code of Regulations, Title 22, Division 6 as a result of today's meetingthe state’s words, verbatim · CDSS document, Jul 18, 2022

Type of visit: Post Licensing

On 4/14/22 Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived unannounced to conduct a post licensing inspection. The facility is a two story building with one central entrance. LPAs were allowed access to the facility and were temperature screened and COVID symptom screened. COVID signage was observed to be posted in the facility. LPAs Jensen and Bilger toured the physical plant and the grounds including the kitchen, dining hall, activity room, common bathrooms and resident rooms. The facility was found to be clean and sanitary and contained adequate lighting and furniture for the comfort of the residents. The temperature in the facility was observed to be set at 72 degrees which is in the required range of between 68 degrees and 85 degrees. The facility has two stairwells and both are equipped with emergency evacuation chairs. Water temperature in the bathroom was measured at 116 degrees which is within the required range of 105 degrees and 120 degrees. The refrigerator was set at 36 degrees and the freezer was set at 10 degrees. LPAs observed an adequate emergency supply of water and food. LPAs observed the facility to have in excess of 2 days of perishable food and in excess of 7 days of non-perishable food. LPAs observed and reviewed ServSafe certifications for kitchen staff and a complete MSDS manual. The fire extinguishers were last serviced on August 16th, 2021 and are in compliance. LPAs observed that there are renovations currently in progress at the facility. LPAs interviewed staff 1 who advised that there are 16 residents on the second floor. LPAs observed a storage room on the second floor directly across from the elevator that was unlocked and contained multiple toxins accessible to the residents. In addition, there is a sliding door on the second floor that allows access to the roof. The sliding door was observed to be open with only a screen that was shut but not locked leaving the roof accessible to residents. The roof has an uneven surface and poses a safety threat with tripping hazards to residents. Staff files were reviewed for staff 2 (S2), staff 3 (S3) and staff 4 (S4). The first aid/CPR certificate for S2 was observed to be expired as of 12/12/21. There were deficiencies found and cited from the California Code of Regulations (CCRs) - Title 22. An exit interview was conducted and a copy of this report was given to the Resident Care Coordinator Andrea Eldridge.the state’s words, verbatim · CDSS document, Apr 15, 2022

Type of visit: Case Management - Incident

On 4-15-22 at 3:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Maja Jensen arrived unannounced to conduct a case management visit for an incident reported on 3-3-22 which occurred on 3-2-22.. LPA met with Resident Care Coordinator (RCC) and explained the purpose of the visit. Administrator Alma Whitted was informed of LPAs visit and gave permission for Andrea to sign in her absence and accommodate LPAs. LPAs reviewed incident report with RCC and interviewed RCC. Based on record review and interview it was determined that Resident1 (R1) was sent to the hospital on 3-2-22 after experiencing shortness of breath and a fall while in the shower. R1s shortness of breath and fall occurred at 12:30pm on 3-2-22 and 9-1-1 was notified by staff. R1 was then transported to acute hospital at approximately 1:00pm and officially admitted on 3-3-22. R1 remained in hospital until 3/14/22 at which time R1 was transferred back to facility and began receiving hospice services on 3/14/22. On 3-22-22, licensing department received a death report stating R1 expired on 3/19/22 while under hospice care due to acute cebrol vascular stroke. Based on record review it was determined that reporting requirements and emergency procedures for above incidents were followed appropriately. No deficiencies cited during today's visit. An exit interview was conducted with Andrea Eldridge and a copy of this report was left with Andrea.the state’s words, verbatim · CDSS document, Apr 15, 2022

Allegation investigated: Facility has bed bugs

On 4/15/22 at 9:30am Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived at the facility unannounced to deliver complaint investigation findings related to the above allegation. LPAs met with Resident Care Coordinator Andrea Eldridge and explained the purpose for today's visit. LPA Maja Jensen interviewed staff 1 (S1) on 3/30/33, staff 2 (S2) on 2/25/22, staff 3 (S3) on 2/25/22 and resident 1 (R1) on 2/25/22. LPA Jensen toured multiple resident rooms on 2/25/22. On 4/14/22 LPA Jensen reviewed a monthly service contract with a pest control service dated 2/22/22 and service receipts for November 2021 and December 2021. LPAs Jensen and Bilger observed on 3/30/22 that the facility has conducted renovations that include replacing all carpeting with laminate flooring and the facility has purchased new furniture to replace all existing furniture. On 4/15/22 the Resident Care Coordinator advised that the facility is currently clear of bed bugs. This allegation is UNSUBSTANTIATED. Based on the observations, interviews and records reviewed, the facility is taking all actions necessary to control and eradicate pest infestation. An exit interview was conducted and a copy of this report was left with the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 14, 2022 · control 27-AS-20220222163759

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.

Allegation investigated: Personal Rights

On 3-30-22 at 10:00am Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived at facility unannounced to continue a complaint investigation and deliver complaint findings for the allegations noted above. LPAs were allowed access to the facility and screened at the front door for COVID symptoms. LPAs Jensen and Bilger met with Administrator Alma Whitted and Resident Care Coordinator and informed of the purpose of today's visit. LPAs Maja Jensen and Michael Bilger conducted interviews with 5 residents and 4 staff members. In addition LPA Maja Jensen observed the interactions between staff and residents during the course of three visits, specifically on 1/24/22, 2/25/22 and 3/30/22. The personal rights allegation is related to the accusation that staff is speaking to residents in a disrespectful manner. Based on the interviews conducted there was no coroboration that a violation of personal rights occurred and the preponderance of evidence standard was not met therefore this allegation is UNSUBSTANTIATED. An exit interview was conducted with Alma Whitted, and a copy of this report was left with facility. Unsubstantiated Additionally, based on interview, it was determined that on 3-12-22 a staff member was absent from the floor for a period of 2.5 hours creating an insufficient staffing event. Based on interviews conducted and records reviewed, the preponderance of evidence standard is met. Therefore, this allegation is SUBSTANTIATED. An exit interview was conducted with Alma Whitted and a copy of this report was left with Alma. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 30, 2022 · control 27-AS-20220118104227

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 31, 2022

Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews and record reviews, staff was not scheduled and available during the dates of 1/11/22. Additionally, a staff member who was on schedule was absent from care for 2.5 hours on 3-12-22. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 30, 2022

Plan of correction: Licensee will submit a plan to ensure sufficient staff is available to meet resident needs by POC due date.

Allegation investigated: Questionable death Residents are not properly assisted with incontinence care Facility is not following residents' hospice care plans Facility is malodorous

On 3-30-22 at 10:00am Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived at facility unannounced to continue a complaint investigation and deliver complaint findings for the allegations noted above. LPAs were allowed access to the facility and screened at the front door for COVID symptoms. LPAs Jensen and Bilger met with Administrator Alma Whitted and Resident Care Coordinator and informed of the purpose of today's visit. LPAs reviewed resident files which included a physician report, needs and service plans, admission agreements, various special incident reports and home health agency narratives. LPAs also reviewed records for hourly check logs, care logs, death reports, police department incident reports, American Medical Response reports and 911 call logs. In addition LPAs conducted interviews with residents, staff and hospice workers. The Investigations Bureau (IB) conducted an investigation in to allegation 1. Questionable Death continued......... Unsubstantiated Based on records reviewed by the IB, the preponderance of evidenced standard is not met, therefore this allegation is UNSUBSTANTIATED. Allegation 2. Residents are not properly assisted with incontinence care, was found to be unsubstantiated based on record reviews and interviews with staff and residents. LPAs interviewed staff1 (S1), S2, S3, S4. LPAs also interviewed resident1 (R1), R2. Additionally, LPA interviewed two hospice staff members who manages a total of 6 hospice residents in care at facility. LPA also reviewed care logs for incontinence care. Care logs indicate incontence care is consistently performed for residents in care. Interviews conducted did not reveal a lack of incontinence care performed. Based on interviews conducted and records reviewed the preponderance of evidenced standard is not met, therefore this allegation is UNSUBSTANTIATED. Allegation 3. Facility is not following residents' hospice care plans, was found to be unsubstantiated based on interviews conducted with Hospice Case Managers. Based on interviews conducted and records reviewed the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED. Allegation 4. Facility is malodorous, was found to be unsubstantiated. LPA Maja Jensen visited the facility on three separate occasions to conduct complaint investigations and was not able to detect an unusual odor. The allegation is also unsubstantiated based on interviews conducted with residents. Based on interviews conducted and a physical sensory assessment of the facility the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to the facility. This allegation NEEDS FURTHER INVESTIGATION. This report is replaced by 9099 dated 4/15/22the state’s words, verbatim · CDSS document, Mar 30, 2022 · control 27-AS-20220121155252

Allegation investigated: Positive COVID-19/symptomatic staff are required to work at the facility

On 3-30-22 at 10:00am Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived at facility unannounced to continue a complaint investigation and deliver complaint findings for the allegations noted above. LPAs were allowed access to the facility and screened at the front door for COVID symptoms. LPAs Jensen and Bilger met with Administrator Alma Whitted and Resident Care Coordinator Andrea Eldridge and informed of the purpose of today's visit. LPAs Maja Jensen and Michael Bilger reviewed COVID screening logs, payroll logs and staffing schedules. LPA Jensen also conducted interviews with staff 1 (S1) and staff 2 (S2) and resident 1 (R1). LPA Jensen observed that on 1/18/22, 1/19/22, 1/20/22 and 1/23/22 staff members documented that they were experiencing COVID symptoms. On 1/16/22 a staff member documented that they were experiencing COVID symptoms and tested positive. LPAs also verified that the staff that confirmed they have COVID sypmtoms worked on the dates they attested to having symptoms. In addition, during the course of an interview, S2 and advised there was pressure to come to work despite complaining of being symptomatic with COVID. During the course of an interview with R1, R1 advised they learned that staff was pressured to come in to work despite not being able. Based on the COVID screening logs and interviews conducted the preponderance of evidence standard has been met, therefore this allegation is SUBSTANTIATED. Substantiatedthe state’s words, verbatim · CDSS document, Mar 30, 2022 · control 27-AS-20220121155252

From the deficiency page — Deficiency type: Type A · Section cited: CCR 3205(c)(2)(B) · Plan of correction due date: Mar 30, 2022

COVID-19 Prevention The employer shall develop and implement a process for screening employees with COVID-19 symptoms. This requirement was not met as evidenced by based on COVID screening logs for teh dates of 1/18/22, 1/19/22, 1/20/22 and 1/23/22 the licensee did not ensure the rights of persons in care to safe and health accomodations in that staff members were allowed to work while experiencing COVID-19 symptoms, which poses a threat to the health and safety of clients.the state’s words, verbatim · CDSS document, Mar 30, 2022

Plan of correction: The licensee shall agree to not allow employees to work that are symptomatic or test positive and are symptomatic with COVID-19. This is an amendment of the LIC 9099-D of 3/30/22 and replaces the LIC 9099-D of 3/30/22.

Type of visit: Case Management - Other

On 3-30-22 at 4:50pm, Licensing Program Analysts (LPAs) Michael Bilger and Maja Jensen conducted a case management visit relating to a complaint visit conducted for #27-AS-20220118104227. During an interview with R1 and facility observation it was determined that R1s emergency signal system was not functioning. LPA Jensen activated signal system at 2:29pm. No response was heard by staff and no indication on monitoring system was observed. Based on LPAs observation, deficiencies are cited as a result of today's visit under Title 22, Division 6. An exit interview was conducted with Alma Whitted and a copy of this report was left with Alma. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 30, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(A)(B)(C) · Plan of correction due date: Mar 31, 2022

Maintenance and Operation (i) Facilities shall have signal systems which shall...(1)All facilities licensed for 16 or more...shall:(A)Operate from each resident's living unit.(B)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. (C) Identify the specific resident living unit. This requirement is not met as evidenced by: Based on observation and interview, it was determined that R1s facility's signal system did not function. This poses an immediate health, safety, and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 30, 2022

Plan of correction: Licensee will submit plan to ensure resident needs are met with alternative signal system until current system is repaired or replaced. Plan to be submitted to LPA by POC due date. POC visit to be planned. Licensee will repair or replace current signal system to meet regulatory requirements. A time frame for repair or replacement to be submitted to LPA by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) Maja Jensen and Avelina Martinez arrived unannounced to conduct a case management visit on 3/16/22 at 9:40 am. LPAs were granted access to the facility and screened for COVID upon entering. LPAs met with Administrator Alma Whited and explained the purpose of today's visit. LPAs Maja Jensen and Avelina Martinez conducted today's case management due to concerns over deliveries not being received. LPAs Maja Jensen and Avelina Martinez conducted interviews at the facility to confirm the delivery procedures with staff and also verified that the issue had been resolved. As a result of today's visit no Title 22 deficiencies were observed and a copy of this report was given to the facility administrator.the state’s words, verbatim · CDSS document, Mar 16, 2022

Allegation investigated: Lack of care and supervision Facility has bedbugs buildings and grounds not safe and sanitary

On 02/25/2022, Licensing Program Analysts (LPAs) Avelina Martinez and Maja Jensen conducted an unannounced complaint investigation regarding the above allegations. LPAs discussed the purpose of the visit with Administrator, Alma Whitted. Throughout the investigation, LPA Jensen conducted interviews, toured the facility, and obtained facility records. During the Feburary 25, 2022 visit, LPA Jensen observed cigarette butts in non-designated smoking areas on the resident patio. LPA Jensen observed cigarettes in the flower bed, patio sidewalks and throughout the landscaping. In addition LPA Jensen observed a discarded surgical mask in the resident gazebo sitting area as well as miscellaneous trash including paper wrappers and plastic bag. The gazebo benches were unsanitary. Continued... Substantiated The exterior covered patio overhang was observed to have exposed wires adjacent to the emergency exit door. The resident patio sidewalk leading to the southside of the building was observed to have a garden hose laying across the path which creates a tripping hazard for residents. A broken electrical outlet was also observed on the path leading to the southside of the building. LPA Jensen observed the rear of the southside of the building has overgrown grass, a pile of dirt and debris and heavy machinery that is exposed and accessible to the residents. The roof of the southside of the building was observed to be missing a tile. LPA Jensen observed 5 window screens on the first level that were torn and not in good repair. In the interior of the facility LPA Jensen observed the following: Dining hall baseboards that had peeling paint, cracks and were seperating from the wall. Two spiders near the cracked baseboards in the dining hall south corner. Walls in the dining room with holes in the drywall Uneven transition strip not in good repair by emergency exit door in the dining hall causing a tripping hazard Several floor boards in the dining hall not in good repair An electric outlet with a cover not installed properly A camera on the ceiling between the dining hall and front desk with exposed wires A ceiling tile by the activity room next to the stairs with water damage and mold Resident 1's room was observed to have a fire alarm with exposed wires Resident 1's room was observed to have a bent screen that was not in good repair The Administrator confirmed the facility had at least two known cases of bed bugs which started February 18. The Administrator advised a pest service was called out to the facility on February 21 and the facility is waiting to receive the pest control report which has been delayed due to bereavement leave of pest control staff. Off duty personnel was observed entering the facility without a mask and without signing in or being screened. Continued...... Moreover, during the complaint investigation visit, LPA Jensen shadowed facility staff 1 (S1) delivering tray service at lunch. At 12:06pm lunch was delivered in room to resident 3 (R3), at 12:07 lunch was delivered in room to resident 4 (R4) and S1 called another staff member (S2) to feed R4, S2 arrived within 4 minutes minutes. At 12:12pm lunch was delivered in room to resident 5 (R5), at 12:16pm lunch was delivered in room to resident 6 (R6). When lunch was delivered to R6, R6 complained of pain and S1 called staff 3 (S3) on the radio to respond. S3 did not arrive to the room of R6 until 12:44pm and at that time R6 received pain medication. As a result of S3 being occupied with other residents, R6 had to wait 28 minutes for pain medication. As a result of this visit, the following deficiencies were cited, per Title 22 Regulations. The deficiencies were cited on 9099-D. Immediate civil penalty of $500 for not ensuring the personal rights of persons in care to safe and healthful accommodations is being issued on February 25, 2022. REPEAT VIOLATIONS 1. Violation of California Code of Regulations Section 87303(a). A previous licensing report was issued on 1/24/22 giving notice of the same violation. A $1000 civil penalty was issued on today's visit of 2/25/22. An exit interview was conducted and a copy of this report was given with appeal rights.the state’s words, verbatim · CDSS document, Feb 25, 2022 · control 27-AS-20220222163759

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Mar 31, 2022

873039a) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met based on observation of LPA observing the building and grounds to be unsanitary and not in good repair. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2022

Plan of correction: Administrator agrees complete all repairs by 3/31/22.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: Mar 4, 2022

Health and Safety Code 1569.50(a)(3) Conduct Inimical: Conduct which is inimical to health, morals, welfare or safety of either an individual in, or receiving services from the facility or the people of the State of California. This requirement was not met as evidenced by based on observation the facility did not follow proper usage of face covering and did not implement COVID-19 pre-screening measures at entrance of facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2022

Plan of correction: The Administrator agrees to conduct a donning and doffing training for all staff and conduct a training for front desk staff on pre-screening of residents by 3/4/22.

Type of visit: Case Management - Deficiencies

On 2/25/22 LPAs Maja Jensen and Avelina Martinez conducted a case management visit. During the course of this case management LPAs toured resident rooms and conducted facility interviews. The purpose of the case management visit is to follow up on deficiencies found during complaint investigation 27-AS-20220222163759. Resident 2 (R2) was observed to have malfunctioning call buttons in their room. LPA Avelina Martinez tested the call button system and it was observed that the living room and bedroom call buttons were transposed. In addition LPA Jensen observed a resident room was converted to an office. As a result facility sketch does not reflect this change. Moreover LPA Jensen reviewed hourly check logs for 3 residents. It was observed that the one hour and two hour check logs for three residents had missing entries for 2/10, 2/11, 2/16, 2/17, 2/22 and 2/23. As a result residents are not receiving the required care. As a result of this visit, the following deficiencies were cited, per Title 22 Regulations. The deficiencies were cited on 809-D. An exit interview was conducted and a copy of this report was given with appeal rightsthe state’s words, verbatim · CDSS document, Feb 25, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Mar 11, 2022

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 in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources This requirement was not met as evidenced by based on observationa and record review of R3, R4 and R5 hourly check log did not reflect that residents were being checked hourly therefore residents did not receive the required care. This poses a potential health and safety risk to residents R3, R4 and R5the state’s words, verbatim · CDSS document, Feb 25, 2022

Plan of correction: Administrator agrees to review all hourly check logs and conduct care and supervision training for all care staff and med techs. Administrator agrees to submit training documentation to LPA by email by POC date 3/11/22

From the deficiency page — Deficiency type: Type B · Section cited: CCR87208(a)(7)(B) · Plan of correction due date: Mar 11, 2022

Plan of Operation87208(a)(7)(B) Each facility shall have and maintain a current, written definitive plan of operation...Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval..Sketches, showing dimensions, of the following: The grounds showing buildings, driveways, fences, storage areas, pools, gardens, recreation area and other space used by the residents.This requirement was not met as evidenced by based on observation resident room 119 is being utilized as an office for staff. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2022

Plan of correction: The Administrator agrees remove the office and revert this space back to a resident room by 3/11/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Mar 11, 2022

87303 i(1)(A) Maintenance and Operation Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement was not met as evidenced by based on observation call button page alert displaying misinformation. This posed a potential threat to the Health, Safety, and Personal Rights of all residents in care.the state’s words, verbatim · CDSS document, Feb 25, 2022

Plan of correction: Administrator agrees to repair the

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) T. White and M. Jensen made an unannounced visit on this day for the purpose of conducting a Case Management, Health and Safety visit. LPAs met with Carla Little, Community Relations Director and explained the purpose of the visit. LPAs toured the facility, including but not limited to, bedrooms, bathrooms, kitchen, and common areas. LPAs verified that the facility had running water and electricity. LPAs observed sufficient PPE supplies. LPAs inspected food supplies and observed 7 days worth of perishable and 2 days worth of non-perishable foods. The following deficiencies was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. An exit interview was conducted with Community Relations Director. A copy of this report and Appeal Rights given.the state’s words, verbatim · CDSS document, Jan 24, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jan 25, 2022

87309(a): 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 requirement was not met as evidence by: Based on observartion, facility did not comply with the section cited above. LPAs observed unlocked tools and chemicals accessible to residents which is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2022

Plan of correction: Facility agreed to lock it tools and chemicals. Facility will submit proof to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jan 28, 2022

87303(a): Maintence and Operation :(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidence by: Based on observation, Facility did not comply with the section cited above in 87303(a). LPAs observed debris and cob webs throughout the facility, which is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2022

Plan of correction: Facility agreed to clean up debris and cob webs and submit proof to CCLD by POC date.

Type of visit: Prelicensing

On 12-16-21 at 1:05pm, Licensing Program Analyst (LPA) Michael Bilger conducted an unannounced pre-licensing visit to this facility. LPA met with Administrator Alma Whitted and explained the purpose of the visit. Brief interview was conducted with the Applicant who was contact by phone during visit. It was learned that this facility will be licensed as a Residential Care Facility for the Elderly (RCFE) to serve up to 160 residents. There were 56 residents present during today's pre-licensing visit, 8 residents are on hospice. Tour of the facility was conducted. Dining area, common areas, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. COVID Precautions in place including signage, PPE storage and 30-day supply. Isolation rooms designated. LPA observed no obstruction of emergency exits. Exit signs in place as appropriate. Fire extinguishers in place upstairs and downstairs and fully charged. Facility map indicating emergency exits posted in appropriate locations. Complaint poster and Ombudsman Poster observed. Kitchen area was toured. Food supply for 2-day perishable and 7-day non-perishable quantities were reviewed to make sure that this facility is in compliance at this time. Medication room, located on first flour, was toured. First aid kit was observed to be present and contained all required components at this time. Medication count for 3 of 3 residents was conducted which matched MARS and centrally stored logs. 3 of 3 resident bed rail orders verified. 4 of 4 staff charts were reviewed and complete. A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the clients were observed to be sufficient and able to meet the needs of the clients at this time. A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured at 109.4*F which is within the allowed range of 105-120 degrees. A tour of the exterior grounds was conducted. {Cont. on 809C) Side gates, and walkways were observed to be maintained in compliance at this time. Carbon Monoxide detectors and fire alarms and smoke detectors are in working order. Window screens were observed to be in good repair at this time. Water fountain in hallway has been removed and ceiling tiles have been replaced. Hazard materials observed to be inaccessible to residents in care. Signal system was tested and observed to be functional, with staff response time within 30 seconds. Resident rooms with oxygen observed to have appropriate signage on doors. Chair lifts noted in each stairwell during today’s visit. LPA received updated resident roster. Ceiling tiles and drywall on second floor has been replaced. Flooring on second floor is replaced. This facility has been found to be in compliance at this time. There were no deficiencies observed during today's Pre-licensing visit. Component III completed with Administrator Alma Whitted with applicant’s permission via phone during visit. Exit Interview conducted with Alma Whitted. A copy of this report was left with the Alma.the state’s words, verbatim · CDSS document, Dec 16, 2021

Type of visit: Prelicensing

On 10/15/2021 at 1:10pm, Licensing Program Analyst (LPA) Ashley Boothe, arrived unannounced to conduct a conduct a Prelicensing Inspection for a Change of Ownership Application. LPA met with Administrator and explained the purpose of today’s inspection. Administrator, applicant on site, and current licensee gave verbal designation for Designee Staff one (S1) to accompany LPA during today's inspection. Current Census is 56 of which 6 are hospice. LPA observed resident roster last updated on 8/22/2021. LPA observed Administrator Certificate expires on 10/10/2021. 4 of 4 staff observed with criminal record clearance associated in the Licensing Information System (LIS). LPA and S1 toured the facility inside and outside to ensure the safety of the residents, interacted with a random number of residents during this visit and observed residents engaged in dining and games in communal living room. Observed resident rooms, restrooms, medications room, dining room, communal areas, patio, kitchen, and staff offices. The temperature inside the facility was measured at 76*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30 *F less than the outside temperature. Observed air conditioning system not in working order and plan in place all residents have access to individual air conditioning units to be maintained in working order at all times. The heater repaired on 10/14/2021 faulty switch replaced found to be in working order. The hot water was measured between 110*F and 113 *F which is not less than 105*F and not more than 120 *F. Resident's Personal Rights, Resident Counsel, and Let Us Know posting in main area accessible to all residents, family, visitors, and staff. Observed fire extinguisher last inspected on 8/15/2021, pull alarm system. Fire sprinkler system last inspected on 9/2/2021. Continued on 809. Continued from 809. Observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. Kitchen staff two (S2) is current with serve safe certification. Hand washing sink with soap, paper towels, hand washing sign, and covered trash can. Hot water signs posted to notify of water above regulatory range. Refrigerator and freezer temperatures were within adequate range per regulations. Observed knives inaccessible to residents. Observed dining room with tables and chair setup for social distancing and communal meals and small group activities. Observed south corridor second floor inaccessible to residents with stripped dry wall and flooring. Administrator stated second floor repair work completion is expected 60 days. Observed two of two storage rooms unlocked and accessible to residents housing paint and construction supplies. Observed residents rooms under construction with signs posted "do not enter" but door handles removed, not in good repair with exposed wires and piping. Observed ceiling tiles missing on first floor south corridor and north corridor damaged wall from water fountain removal. Observed carbon monoxide detectors not in working order or removed. Observed two window screens off window on first floor. Observed outside a pile of loose bricks, fallen tree branch, and shed not in good repair on the facility property. Observed call system in working order but Staff three(S3) stated they did not have a phone or access to a phone since starting two and a half months ago. Staff four (S4) phone in working order. Observed staff did not respond to two calls to second floor rooms and S3 responded to S1 on the walkie talkie 7 minutes after pull cord was activated. Observed no chairlifts in the three stairwells and S1 stated unaware if any were on site. Observed resident room 106 to use oxygen and no signs posted to demark. Observed the centrally stored medications area to be locked and inaccessible to residents. Observed medications room, three of three medications counted matched MAR's and Centrally Stored Log. Observed PRN documented. Observed Resident one (R1) with bedrails and no physician's order filed. One of three resident files reviewed with no current admissions agreement on file for the facility. Continued from 809 C. The following are required before facility can be approved for licensure: 1. Repair or replace carbon monoxide detectors are in working order. 2. Repair or replace window screens 3. Repair or replace ceiling tiles, dry wall from water fountain, and rooms not in good repair 4. Repair, replace, or remove pile of loose bricks, fallen tree branch, and shed not in good repair 5. Ensure all hazardous items stored or areas are made inaccessible to residents 6 Ensure all staff have access and training to use of the call system to provide care and supervision 7. Ensure all residents with bedrails have documented physician's order. 8. Ensure all rooms are demarked for Oxygen usage when in use 9. Ensure all stairwells chair lifts are maintained at all times 10. Update Resident roster 11. Ensure all resident and staff files are complete and up to date. LPA requests Applicant notify when the above requirements have been met and the facility is ready for re-evaluation for licensure. At this time the facility is not approved to be licensed. A follow up report documenting corrections will be created once corrections are received and application approved. Per the California Code of Regulations, Title 22, no deficiencies cited. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Oct 15, 2021

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.