Mother Mary Care Home

Type of visit: Case Management - Legal/Non-compliance

On 6-20-23 at 9:00am, a meeting was held with licensee to discuss a Technical Support Program Engagement Summary (TSP) generated on 05/25/2023. This meeting was held virtually via Teams Meeting. Present at this meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Maja Jensen, LPA Jennifer Fain, and Ombudsman Kathryn Thomas. At the beginning of the meeting, Licensee confirmed receipt of TSP material from virtual visits on 2/7/23, 2/23/23 and 3/2/23 as well as the on site visit from 2/23/23. LPM and LPA discussed the following topics previously addressed at the TSP Engagement: · Client assessments update requirements · Licensee generated system to track specific files requiring updates · Use of CARE tools to aid in maintaining compliance · Communication with LPA to preemptively address discovered issues and resolutions · Assessment procedures to ensure staff are able to meet needs of clients · Reporting requirements such regulatory requirements and what constitutes an incident report · Medication Management including destruction of Medication and PRN’s Continued on LIC 809C.... Continued from LIC 809... The Licensee has agreed to the following: A medication audit to be completed by the 6/30/23 with audit results submitted to LPA Maja Jensen at maja.jensen@dss.ca.gov. Submission of the Needs and Service Plan tracking system currently in place to be submitted to LPA Maja Jensen at maja.jensen@dss.ca.gov by 6/30/23 A medication training refresher for all staff to be completed within 90 days A Reporting Requirements training refresher for all staff to be completed within 90 days No citations issued today. An exit interview was conducted with Jean Alvarez and a copy of this report was emailed to Jean with a request to return with signature to maja.jensen@dss.ca.gov.the state’s words, verbatim · CDSS document, Jun 20, 2023

Type of visit: Required - 1 Year

On 5/8/23 at approximately 1:20pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a required 1 year annual inspection. LPAs Jensen and Fain met with care provider Jose Alvarez and explained the purpose of today's visit. The Licensee/Administrator Jean Alvarez is away and an LIC 308 assigning responsibility to Jose Alvarez in the Administrator's absence was received by the Department. The Administrator holds current Administrator's certificate # 6061970740. LPAs Jensen and Fain toured the physical plant and grounds. The grounds were observed to be maintained and outdoor furniture in a shaded area is available for resident use. The facility currently has 3 residents in care. LPAs Jensen and Fain inspected the bedrooms, bathrooms, kitchen, staff quarters and common areas. The thermostat was set at 72 degrees for the comfort of residents in care. Knives, toxins, cleaning supplies were observed to be locked and inaccessible to residents in care. There are currently 2 bedrooms in use, both rooms are double occupancy. 2 of 2 residents bedrooms did not have lamps available. The bathrooms were equipped with grab bars in the shower and at the toilet. The water temperature in the main bathroom adjacent to the common area was measured at 115 degrees which falls within the required regulatory range of 105-120 degrees Fahrenheit. The facility maintains a 2 day supply of perishable food and a 7 day supply of non-perishable food. There is also an adequate supply of linens. The fire extinguisher was last serviced in April of 2023 and is in compliance. The carbon monoxide detector was tested and found to be in working order. The first aid kit was observed to be complete with scissors, tweezers, thermometer, various wound dressings and manual. LPA Jensen reviewed 3 of 3 resident files and 2 of 2 staff files. 1 of 3 resident files were missing safeguards for personal property. 2 of 2 staff files were determined to be complete and in compliance. LPA Jensen interviewed 2 of 3 residents in care. Continued on LIC 809C... LPA Jensen observed PRN medication and 2 disposable razors for a resident that has left the facility in late April of 2023 stored on top of a dresser in a resident bedroom. The resident bedroom where the PRN medication was found is a double occupancy room that is currently occupied by a resident. The PRN medications consisted of a variety of solutions, lotions and creams. LPA Jensen interviewed care provider Jose Alvarez who advised the PRN medication is pending destruction. LPA Jensen requested a copy of the LIC 500 and current liability insurance emailed by 5/15/23 to maja.jensen@dss.ca.gov. Deficiencies are being cited from the California Code of Regulations 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, May 8, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 9, 2023

Incidental Medical and Dental Care ... Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Based on LPA Jensen's observation of PRN medication for a resident that has terminated services with the facility that was stored on top of a dresser and accessible to residents in care. This poses an immediate risk to the health, safety and perosnal rights of residents in care.the state’s words, verbatim · CDSS document, May 8, 2023

Plan of correction: The Licensee immediately locked all medications and agrees to email an attestation that this regulation has been read, understood and will be complied with by Plan of Correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(B) · Plan of correction due date: May 22, 2023

Personal Accomodations Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement was not as evidenced by: Based on LPA Jensen's observation of 3 of 3 residents missing a lamp from their bedrooms. This poses a potential risk to the health, safety and persobal rights of residents in care.the state’s words, verbatim · CDSS document, May 8, 2023

Plan of correction: Licensee agrees to place lamps in all resident rooms and ensure that lamps are accessible to residents in care. Licensee will consider using battery operated lamps if a resident has adverse behaviors related to electrical cords.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b)(16) · Plan of correction due date: May 22, 2023

Resident Records .... Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement was not met as evidenced by: Based on LPA Jensen's review of a resident file, Resident 1 did not have a personal property inventory completed upon admission or upon receipt of additional proeprty sent by family members. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 8, 2023

Plan of correction: The Licensee agrees to complete a personal proeprty inventory for resident 1 and email to LPA at maja.jensen@dss.ca.gov by Plan of Correction due date.

Type of visit: Case Management - Health Checks

On 2/3/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management health and safety check related to fire clearance. LPA Jensen met with Jose Alvarez, care giver, and explained the purpose of today's visit. LPA Jensen called Licensee on teh telephone and there was no answer. LPA Jensen left licensee a voicemail. LPA Jensen observed the thermostat in the facility to be set at 67 degrees which is below the required regulatory range of 68-85 degrees. LPA Jensen observed 4 of 4 residents at the facility. 2 of 4 residents were asleep and 2 of 4 residents interviewed advised they were satisfied with the care being received. LPA Jensen inquired about the status of the fire clearance. LPA Jensen was advised that the fire department came out and gave the approved the clearance but did not leave a coy of the paperwork . LPA Jensen received a phone call during the course of the visit from the Licensee. LPA Jensen spoke to Licensee Jean Alvarez who advised that the Fire Marshal stated he would email licensing the clearance on Monday and she assumed Community Care Licensing was in possession of the clearance. LPA Jensen advised no such email was received. **This report is being amended to reflect that the fire clearance was granted for 2 bedridden clients prior to the writing of this report therefore the civil penalty is withdrawn** Deficiencies are being cited form the California Code of Regulations (CCR) Title 22, Division 6. An exit interview was conducted and a copy of this report with appeal rights was given.the state’s words, verbatim · CDSS document, Feb 3, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(1) · Plan of correction due date: Feb 4, 2023

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: This requirement was not as evidenced by LPA Jensen's observation of the facility thermostat temperature reading of 67 degrees upon arrival. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 3, 2023

Plan of correction: The Licensee will send an attestation that the regulation has been read, understood and will bve complied with at all times by the POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR00000 · Plan of correction due date: Feb 4, 2023

Intentionally left blankthe state’s words, verbatim · CDSS document, Feb 3, 2023

Allegation investigated: Staff do not respond to resident's requests for assistance in a timely manner. Staff do not ensure that resident has a way to request assistance from staff while in care.

On 11/9/22 at 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegations. LPA Jensen met with Administrator Jean Alvarez and explained the purpose of today's visit. LPA Jensen observed the facility to be clean and free of odor upon arrival. There was a sign in table observed and all required postings were observed. LPA Jensen checked the food supply and observed teh facility to have 2 days of perishable food and 7 days of non-perishable food. LPA Jensen interviewed Administrator Jean Alvarez regarding the telephone service and resident care. She stated that residents are checked on every 30 minutes to one hour and are turned every 2 hours. Resident 1 (R1) has a call button that sends an alert to the kitchen. LPA Jensen checked the call button and determined it to be in good working order. Administrator Jean Alvarez was unable to confirm the date the call button was put in to place. Continued on LIC 9099C... Unsubstantiated LPA Jensen interviewed 4 of 4 residents. 3 of 4 residents advised they always receive any assistance they need in a timely manner. 3 of 4 residents advised they have the ability to communicate with whomever they choose whenever they choose. LPA Jensen interviewed a San Joaquin County hospice worker and was advised she has no concerns about the quality of care. LPA Jensen also interviewed Staff 1 (S1) who stated that residents are checked every 30 - 60 minutes. Based on interviews conducted with 4 of 4 clients, 1 hospice worker and 2 staff, the allegation of staff do not respond to resident's requests for assistance in a timely manner has been found to be UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Based on interviews with 4 of 4 residents, interviews with 2 staff members and a test of the call button, the allegation of staff do not ensure that resident has a way to request assistance from staff while in care is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report was provided to the administrator. If friends, family or care providers call the facility and leave messages for the residents, the messages are not being retrieved or relayed to the residents. A finding of substantiated means that the preponderance of evidence standard has been met. Citations are being issued 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 facility Administrator.the state’s words, verbatim · CDSS document, Nov 9, 2022 · control 27-AS-20221031172127

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(14) · Plan of correction due date: Nov 11, 2022

Personal Rights of Residents in All Facilities a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls...This requirement was not as evidenced by: LPA Jensen's observation of 67 unretreived voicemails. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 9, 2022

Plan of correction: Licensee conducted an inservice training on use of the facility answering machine in the presence of LPA Jensen. No further Plan of Correction is required

Type of visit: Case Management - Deficiencies

On 11/9/22 at 10:15am LPA Jensen arrived at facility to open a complaint investigation. LPA Jensen with Administrator Jean Alvarez and explained the purpose today's visit. During the course of the investigation, LPA Jensen discovered deficiencies and conducted a case management. LPA Jensen reviewed a resident file for resident 1 (R1). The file for R1 had incomplete documentation including the LIC 9158, LIC 613C and LIC 603. In addition the resident file was consent forms, emergency contact and ID forms, immunization forms and safeguards for property and valuables. LPA Jensen also determined that R1 and Resident 2 (R2) are bedridden. Both bedridden residents are on hospice care. LPA Jensen reviewed the facility sketch and there are no rooms designated for bedridden. LPA Jensen reviewed the STD 850 and determined there is no clearance for bedridden, only 6 non-ambulatory residents. LPA Jensen reviewed the LIC 200 and determined there is no request for bedridden capacity. LPA Jensen also observed a Inspection Record for Permit for voluntary fire sprinkler system dated 9/14/22. Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6. A civil penalty is also being assessed. LPA Jensen observed the bedridden resident rooms to have exit doors and the facility had what appeared to be a fire sprinkler system. An exit interview was conducted a copy of this report along with appeal rights was provided to the Licensee.the state’s words, verbatim · CDSS document, Nov 9, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(l) · Plan of correction due date: Nov 10, 2022

...Nothing in this section [which deals with terminally ill residents and hospice care] shall be construed to relieve a licensed residential care facility for the elderly of its responsibility to notify the appropriate fire authority of the presence of a bedridden resident in the facility as required under subdivision (f) of Section 1569.72 and to obtain and maintain a fire clearance as required under Section 1569.149. This requirement was not met as evidenced by: Based on LPA's review of records including resident file, LIC 200, facility sketch and STD 850 as well as the interview with Administrator Jean Alvarez, there are two residents that are bedridden and no fire clearance for bedridden residents. This poses an immediate risk to the health , safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Nov 9, 2022

Plan of correction: Licensee will complete a new LIC 200 and update the facility sketch to reflect the rooms designated for bedridden residents. Licensee will email it to maja.jensen@dss.ca.gov. LPA Jensen will assist Licensee in completing the STD 850 and sending it to the Fire Marshal by 11/10/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Nov 30, 2022

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident ... This requirement was not met as evidenced by: Based on LPA Jensens review of records for resident 1 which contained multiple incomplete and missing documents. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 9, 2022

Plan of correction: The Licensee agrees to participate in the Technical Support Program offered by Community Care Licensing. LPA Jensen will forward the program information to the Licensee and the Licensee will make arrangements for engagement with the program by the Plan of Correction due date.

Type of visit: Case Management - Health Checks

On 10/26/22 at 4:15pm, Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a health and safety check. LPA Jensen met with Administrator Jean Alvarez and explained the purpose of today's visit. LPA Jensen toured the facility including bathroom, two bedrooms, living room and basement/storage room. The temperature in the facility was set at 72 degrees which falls within the regulatory range of 68-85 degrees. The facility has implemented a water temperature log which was observed to be current through today. The water temperature readings were between the required regulatory range of 105-120 degrees. LPA Jensen observed 2 days of perishable food and 7 days of non perishable food on hand. The bathrooms were observed to have grab bars and non slip mats. The bedrooms were observed to be adequately furnished and the rooms were equipped with adequate lighting. LPA Jensen engaged with 2 of 4 residents during the course of the visit. Both residents stated they are well and satisfied with the facility. The facility has acquired a supply of clothing to keep on hand in the event that a resident comes to them without clothing. LPA Jensen also observed the facility to be sanitary and free of odor. No deficiencies are being cited today from the California Code of Regulations (CCR) Title 22, Division 6. An exit interview was conducted and a copy of this report was handed to the Administrator.the state’s words, verbatim · CDSS document, Oct 26, 2022

Type of visit: Post Licensing

Licensing Program Analysts (LPAs) Albert Johnson and Kesha Lewis arrived unannounced to conduct an annual inspection. LPA met with Jose Alvarez and explained the purpose of the visit. Later joined by Jean Alvarez. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, medication room, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 125.5 degrees Fahrenheit in resident bathroom sink, which is "not " within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. During the residents file review LPAs observed that R1 did not have medications for four days. R1 moved in on 10/13/22 and has not had his medication as prescribed. Per California Code of Regulations, Title 22 Division 6, Chapter 8, Deficiencies were observed and cited during this visit. Exit interview held with Administrator and a copy of report given at the conclusion of the visit. Failure to submit Proof of Corrections (POC's) by plan of correction due dates may result in civil penalties.the state’s words, verbatim · CDSS document, Oct 17, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80088(e)(1) · Plan of correction due date: Oct 18, 2022

Furniture, Fixtures, Equipment, and Supplies: (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature shall be maintained at not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C This requirement was not met as evidenced by hot water tested at 123.5 in the client's bathrooms. This is an immediate safety hazard.the state’s words, verbatim · CDSS document, Oct 17, 2022

Plan of correction: Facility shall adjusted hot water temperature to not less than 105 degrees F and not more than 120 degrees F. LPA requested hot water temperature logs over the course of the next 3 days to clear the cited deficiency. Hot water logs are to provide proof that hot water is being maintained within the regulatory requirement.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(c)(2) · Plan of correction due date: Oct 17, 2022

87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on observation and records review, the Licensee did not ensure medications ordered for residents are given as prescribed which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2022

Plan of correction: The Administrator has developed a plan on how the facility will follow the Physician's orders and document correctly when medications are missed. Please send the agenda along with the sign-in sheet for the in-service. The facility will also report all incidents of medication errors, missed medication Etc.. to the resident's Primary Care Physician and to the department.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Michael Bilger conducted an announced pre-licensing visit to this facility on 05/24/2022 at 2:00pm and was met by the Applicant, Jean Alvarez, Brief interview was conducted with the Applicant. It was learned that this facility will be licensed as a Residential Care Facility for the Elderly (RCFE) to serve up to 6 non-ambulatory clients. There were no clients present during today's pre-licensing visit. Tour of the facility was conducted. Dining area, living area, 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. COVID-19 Mitigation plan is in place. LPA observed no obstruction of emergency exits. Exit signs in place as appropriate. Fire extinguisher in various locations including kitchen, living room, laundry room, and outside area, and are fully charged. Facility map indicating emergency exits posted in appropriate locations. Complaint poster and Ombudsman Poster observed. Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. Areas for sharp objects and toxins were secured with lock. Medication cabinet, located in the kitchen area, was toured. First aid kit was observed to be present and contained all required components at this time. 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. {Cont. on 809C} Hot water temperatures were taken and measured between 105-120*F. Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time. A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. A generator is in place in case of power outage. 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 applicant during visit. Exit Interview conducted with Jean Alvarez. A copy of this report was left with Jean.the state’s words, verbatim · CDSS document, May 24, 2022

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Jean Alvarez Interview Method: Telephone interview On 04/18/2022, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Apr 18, 2022