Sunny Place of Stockton

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

On 10/31/23 at approximately 3:10pm, Licensing Program Analyst (LPA) Jensen arrived at facility unannounced to conduct a visit to ensure compliance with Health and Safety Code (HSC) 1569.38 - Posting of Licensing Reports - Disclosure to new Residents. LPA Jensen met with Administrator Expectacion Vierra and explained the purpose of today's visit. LPA Jensen observed the Accusation posted in the main lobby. The posting was displayed in a location easily viewable by residents and visitors. LPA Jensen interviewed Expectacion Vierra and she confirmed that written notice was handed to existing residents within or on the tenth day after receiving the notification and mailed by US Post to responsible parties. LPA Jensen was given a blank sample notice that was distributed. Based on LPA Jensen's observation and interview the facility is in compliance with HSC 1569.38. In addition, the Department will be contacting the residents or responsible parties to verify that notice was received. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 31, 2023

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

Licensing Program Analyst (LPA) Albert Johnson met with Expectacio Vierra for conducted an unannounced case management visit to issue civil penalty per Health and Safety Code § 1569.49(f). On October 27, 2022, the Department initiated a complaint investigation alleging that the facility staff did not follow the resident’s (R1) care plan and failed to provide proper care to R1. On January 17, 2023, the Department concluded the complaint investigation and substantiated both allegations. The licensee was cited for violating California Code of Regulations (CCR), Title 22, Division 6, § 87464(f)(1) Basic Services and CCR-, Title 22, Division 6, §87405 (h)(5) Administrator - Qualifications and Duties. The investigation revealed that on March 15, 2022, the facility staff reported R1 choked on a hot dog and fell onto the floor. There are conflicting statements whether staff did or did not perform the Heimlich Maneuver. Staff contacted 9-1-1 and started to perform cardiopulmonary resuscitation for seven minutes prior to arrival of the local fire jurisdiction. According to documentation from the fire department, R1 was found unresponsive, pulseless, and apneic upon their arrival. Fire department (FD) staff performed CPR, and then completed a direct laryngoscopy. Continued They pulled out a 1.5-inch piece of a hot dog that caused a full foreign body airway obstruction (FBAO). The FD staff continued CPR which resulted in return of spontaneous circulation. At approximately 4:03 p.m., the paramedics arrived and found R1 lying supine on the ground with facility staff and the fire department present. R1 was still apneic, so R1 was intubated, revived, and subsequently transferred to the hospital. Review of medical records indicated that R1 was revived twice, placed on ventilator for two days, and passed away five days after R1 was taken off from the ventilator. Based on review of R1’s facility record, a memorandum was written and signed by the licensee on February 23, 2022, which states, "Diet: Soft diet only due to missing front teeth. Regular Soft Diet: chopped meat!" This Memorandum indicated R1 was assessed and evaluated based upon R1’s family and the administrator assessment. It was sent to all care staff and marked as urgent. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” Due to the negligence of the licensee in providing a soft diet, R1 choked on a 1.5-inch piece of hot dog and sustained a FBAO. R1 passed away 8 days after hospitalization. Today 10/9/2023 the Department will be issuing a civil penalty per Health and Safety Code 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000.00. However, since an immediate civil penalty was issued on January 17, 2023, the amount of the civil penalty issued today will be adjusted to $9,500.00. A copy of the LIC 421D was given and originals were signed. Exit interview conducted. A copy of the report issued. Appeal rights provided. Expectacio Vierra signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Oct 9, 2023

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

On 8-2-23 at 2pm, a meeting was held with Licensee to review previous engagements by Department’s Technical Support Program (TSP). 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, and Licensee Expectacion Vierra. Topics discussed in this meeting included (1) Care and Supervision, (2) Record Keeping, (3) Incident Reporting (4) Needs and Service Plans, (5) Training Requirements TSP conducted engagement meetings with Licensee on the dates of 4/5/23, 4/12/23, and 4/19/23. TSP addressed care and supervision through providing tools for Needs and Service Plan Development. The Licensee advised the TSP representative that since the non-compliance conference there has been increases to supervision, administrator coverage has increased to 40 hours per week and resident assessments have been updated as February 2023. The licensee was encouraged to document all training efforts and at a minimum to identify the trainer, and include the date, contents, participants and length of the training. Use of the Ombudsman for personal rights training and home health providers was discussed as potential resources for conducting training. The Licensee was encouraged to develop a job aid for kitchen staff to easily recognize the dietary needs of all residents with a modified diet and agreed to do so. TSP addressed record keeping as an area of focus for Licensee due to history of non-compliance. TSP addressed the challenges with licensee conducting and documenting resident assessments and re-assessments. TSP provided training resources and other recommendations to aid in Licensee’s future compliance with this regulated section. Licensee stated during the meeting that she has a staff member that is currently pursuing training for Administrator Certification and she intends to have this staff member take responsibility for record keeping. Continued on LIC 809C... TSP made recommendations for Post-Engagement to assist in facility operation and compliance with laws and regulations. The recommendations include: • Subscribe to CCLD information sharing service. • Complete a facility self-assessment on at least a quarterly basis and record actions taken when issues are identified, maintain a record of assessments and ensure they are available upon request of the CCLD. • Follow recommendations provided by TSP in this Engagement Summary Report and document and retain records showing efforts toward facility compliance in areas of focus. • Review and comply with all laws and regulations specific to the operation of an RCFE. • Review resources, guides, Provider Information Notices, websites, etc., provided in this report and use to aid in compliance. • Use the resources provided through the engagement process for staff training and implementation of changes. Document and retain records of training in the facility file. • Consider affiliating with a provider organization or network. • Consider employing the services of a CDSS-approved administrator certification training program vendor to support the remediation of chronic issues, implement long-term solutions, and provide ongoing support services. Licensee was made aware that quarterly visits will continue at this time to ensure the compliance with above and overall regulatory compliance. No citations issued as a result of today’s visit. An exit interview was conducted with Licensee Expectacion Vierra and a copy of this report was emailed to Licensee with a request to return with signature.the state’s words, verbatim · CDSS document, Aug 2, 2023

Type of visit: Case Management - Health Checks

On 7/3/23 at approximately 2:15pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly health and safety check. LPA Jensen met with Licensee Expectacion (Espie) Vierra and explained the purpose of today's visit. LPA Jensen checked the food supply and determined there was in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. The facility has permanently removed hot dogs from the menu. LPA Jensen determined the posted menu accurately reflected what was served for meals on this day. LPA Jensen reviewed 5 of 10 resident files. 5 of 5 resident files had updated LIC 602's and Needs and Service Plans. 4 of 5 residents have special diets. LPA Jensen provided technical assistance regarding serving the needs of residents with special diets. LPA Jensen observed 10 of 10 residents and all residents appeared to have their needs met. The following trainings have been conducted in 2023: Medications and Care Plans conducted by Wellbe Health Fire and Disaster Emergency Information in-service Aspiration, Dysphagia, Bedsore Prevention and Pain Management in-service Narcotics and PRN Medication in-service Swallowing and Choking by Infinity Hospice LPA Jensen requested an LIC 308 and receieved an updated LIC 308 listing Eleneor Laurora as designee. No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 3, 2023

Type of visit: Case Management - Health Checks

On 4/11/23 at approximately 2:30 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly visit. LPA Jensen met with Licensee and explained the purpose of today's visit. LPA Jensen toured the facility grounds and physical plant. The grounds were observed to be free of debris and all paths were clear. The facility was observed to be sanitary. The thermostat was set at 73 degrees which falls within the required regulatory range of 68-85 degrees. The bathroom water temperature was measured at 117 degrees and is within the required regulatory range of 105-120 degrees. The fire extinguishers and Ansul system was last serviced in March of 2023 and is in compliance. There were three care staff providers, an administrative clerk, two Administrators and a cook on duty when LPA Jensen arrived. LPA Jensen interacted with several residents and observed that all had there needs met. Staffing levels were observed to be sufficient based on a census of 12. LPA Jensen reviewed the training records for staff present at the time of the visit. LPA Jensen reviewed training records for inservice training done on the following dates: 3/16/23 Narcotics and PRN Medication 3/23/23 Aspiration, Dysphagia, Bedsore Prevention, Pain Management 3/30/23 Medication, Care Plans, How to contact PACE LPA Jensen observed 2 days worth of perishable food and 7 days non-perishable food. LPA Jensen reviewed the facility food menu which listed stuffed peppers, Rice Pilaf and Brussel Sprouts listed on the menu. LPA Jensen interviewed a care provider (S1) who advised that lunch service consisted of Ravioli, Cauliflower and Bread. Continued on LIC 809C.... Continued from LIC 809... 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 11, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(6) · Plan of correction due date: Apr 25, 2023

In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. This requirement was not met as evidenced by: Based on LPA's review of the current menu and an interview with staff, the lunch served on this day did not reflect what was listed on the menu which poses a potential risk to health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Apr 11, 2023

Plan of correction: The Licensee agrees to conduct an in-service training with staff and will revise future menus to include alternatives based on resident choice. Licensee will email proof of in-service training by plan of correction due date.

Type of visit: Required - 1 Year

On 2/27/23 at approximately 1:30pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Licensee Larry Vierra in person and with Espie Vierra by telephone. The facility serves residents with Dementia. LPA Jensen toured the facility and grounds. The facility has a single designated entry with COVID screening protocols in place. The facility maintains a 30 day supply of PPE. The facility was determined to be adequately furnished and was observed to have sufficient lighting throughout. The fire extinguisher was last serviced in March of 2022 and is in compliance. The Ansul system was last serviced in March of 2022 and is in compliance. The carbon monoxide detector was determined to be in working order. The facility thermostat was set at 71 degrees which is within the required range of 68-85 degrees. The water temperature in a resident bathroom was measured at 118 degrees which falls within the required range of 105 to 120 degrees. All required signs were posted in areas that were easily visible by residents and staff. The facility was observed to maintain a two day supply of perishable of food and a 7 day supply of non-perishable food. All knives were observed to be locked and inaccessible to residents in care. The dinner service being prepared accurately reflected what was posted on the dinner menu. The medication cart is kept in the dining room. LPA Jensen reviewed 3 resident files. The Centrally Stored Medication and Destruction Record for Resident 1 had no entries for the date medication was started for a PRN Hydrocodone dating back to at least July of 2022. If the medication was started on the same date the Hydrocodone was filled then the Medication Administration Record was inaccurate. 3 of 3 resident CSMDR had missing entries for various medications and LPA Jensen was unable to determine whether the medication was accurate or not. Continued from LIC 809C... LPA Jensen toured the grounds and observed all pathways were clear. There is sufficient outdoor furniture for residents to participate in outdoor activities. LPA Jensen various piles of debris in the back yard of the facility including broken tupperware, paper plates, broken bed frames. discarded mattresses. 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 given.the state’s words, verbatim · CDSS document, Feb 27, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506 · Plan of correction due date: Mar 27, 2023

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident ... This requirement was not met as evidenced by: LPA's review of the CSMDR showed no entries documented for date started for Hydrocodone since July of 2022 and amount of medication dispensed did not match records. This poses a potential risk to teh health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2023

Plan of correction: The Licensee agrees to have an outside vendor conduct training for all staff on medication that at a miinimum includes medication storage and record keeping by Plan of Correction due date. Proof of correction to be sent to maja.jensen@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Mar 27, 2023

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 as evidenced by: LPA's observation of piles of debris in yard. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2023

Plan of correction: The Licensee agrees to remove all debris from the backyard of facility by POC due date and to send photos to maja.jensen@dss.ca.gov.

Allegation investigated: Facility failed to provide DNR to EMT

On 1/17/23 at approximately 01:30 PM Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings for a complaint investigation in to the above listed allegations. LPA Maja Jensen met with Administrator Expectation Vierra and explained the purpose of today's visit. During the course of the investigation, the Department reviewed the full file for resident 1 (R1) as provided by Administrator Expecatcion Vierra, the death certificate for R1, The American Medical Response (AMR) report, medical records and Fire Department records. The Department also interviewed 2 family members of R1, 3 residents of the facility, the Administrator and 4 staff. A review of the facility file for Resident 1 (R1) shows a Physician Orders for Life-sustaining Treatment (POLST) dated 12/31/2018 which states do not attempt to resuscitate, and selective treatment only and another POLST dated 2/20/2020 which states attempt resuscitation/CPR and full medical treatment. Continued on LIC 9099C... Unsubstantiated Based on interviews conducted and medical records reviewed R1 was the recipient of resuscitation efforts and or CPR and received full medical treatment while hospitalized which does not conflict with the POLST. In addition there is no evidence to indicate that the POST was given to the Emergency Medical Team and also no evidence to indicate it was withheld therefore the allegation of the facility failed to provide DNR to EMT is unsubstantiated. An exit interview was conducted and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 17, 2023 · control 27-AS-20221027085402

Allegation investigated: Facility staff did not follow care plan Neglect / Lack of Care Resulting in Death

On 1/17/23 at approximately 12:50pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings for a complaint investigation in to the above listed allegations. LPA Maja Jensen met with Administrator Expectacion Vierra and explained the purpose of today's visit. During the course of the investigation, the Department reviewed the full file for resident 1 (R1) as provided by Administrator Expecatcion Vierra, the death certificate for R1, The American Medical Response (AMR) report, medical records and Fire Department records. The Department also interviewed 2 family members of R1, 3 residents of the facility, the Administrator and 4 staff. Facility Staff Did Not Follow Care Plan During the course of this investigation the Department reviewed a Memorandum dated 2/23/2020 from Expectacion Vierra to all facility staff stating that R1's diet should be a soft diet only due to missing front teeth and a regular soft diet should consist of "chopped meat!" Continued on LIC 9099C... Substantiated Based on medical reports, Fire Department reports and staff interviews, R1 consumed meat that was not chopped on 3/15/22 which resulted in R1 choking on a hot dog therefore the allegation of Facility staff did not follow care plan is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Neglect / Lack of Care Resulting in Death On 3/15/22, R1 choked on hot dog served to her by the facility and died shortly after. The Death Certificate for R1 states R1 died from Acute Hypoxic Respiratory Failure (for days), and the underlying cause is Cardiac Arrest (for days), and Alzheimer's Dementia (for years). The responsible parties for R1 stated they were told R1 choked on a hot dog which got caught in R1’s "airway. " R1 fell onto the floor, so staff was unable to perform the Heimlich Maneuver and they called 9-1-1. R1 was unresponsive and the Emergency Medical Technicians (EMT) were able to revive R1. R1 was taken to the hospital and died eight days later. A Hospital nurse told the responsible party for R1 that R1 arrived at the hospital without her teeth. Administrator Expecatcio Vierra stated a Memorandum document located in R1's file, written and signed by herself and dated 2/23/2020, states "Diet: Soft diet only due to missing front teeth. Regular Soft Diet: chopped meat!" This Memorandum was sent to all care staff and marked as Urgent. A St. Joseph's Medical Center Emergency Room doctor stated R1 was sick and in cardiac arrest when she arrived at the hospital. The paramedics had already removed the item from R1's throat and R1 was intubated at the hospital. R1's teeth/dentures would have been removed when she was intubated. Based on the records reviewed, and interviews conducted, the facility did not ensure that R1 was wearing dentures and/did not serve food suitable for soft diet therefore the allegation of Neglect / Lack of Care Resulting in Death is substantiated. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. A civil penalty in the amount of $500 is being issued on today's visit due to the violation resulting in death of a resident. Failure to correct the deficiency may result in additional civil penalties. At the time of the complaint visit, the issuance of an Enhanced Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49 Appeal rights were provided. Exit interview conducted with Expecacio Vierra. Copy of the report was provided to the Administrator and appeal rights were received.the state’s words, verbatim · CDSS document, Jan 17, 2023 · control 27-AS-20221027085402

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

Basic Services ... Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).... This requirement was not met as evidenced by: Based on interviews with staff, medical personnel, responsible parties and record reviews the facility did not provide for soft food or "chopped meats" as indicated in the memorandum issued to all staff by the licensee. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 17, 2023

Plan of correction: Effective immediately, the Licensee agrees to lock the kitchen door until food is ready to eat so that any dietary modifications needed can be addressed before residents enter the dining room and to ensure that residents are attended to while they consume food. Licensee will email an attestation to maja.jensen@dss.ca.gov by the POC.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(h)(5) · Plan of correction due date: Jan 18, 2023

Administrator - Qualifications and Duties The administrator shall have the responsibility to:... Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs...This requirement was not met as evidenced by: Based on interviews conducted and records reviewed the Licensee was aware that R1 required a soft diet or chopped food and did not ensure the provision of such. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 17, 2023

Plan of correction: Effective immediately, the Licensee agrees to lock the kitchen door until food is ready to eat so that any dietary modifications needed can be addressed before residents enter the dining room and to ensure that residents are attended to while they consume food. Licensee will email an attestation to maja.jensen@dss.ca.gov by the POC.

Allegation investigated: Illegal eviction

On 8/15/22 at 10:45am Licensing Program Analyst (LPA) Maja Jensen arrived at facility to continue an investigation in to the above allegation. LPA Jensen met with Expectacio Vierra and explained the purpose of today's visit. During the course of the investigation, LPA Jensen reviewed records including Physician reports, staff roster, staff schedule and chart notes for resident 1 (R1). LPA Jensen also interviewed Administrator/Licensee who confirmed that client R1 went in to hospital and then a skilled nursing facility at which time the Licensee instructed the resident's Power of Attorney that the client cannot return to the facility due to challenges that had been encountered with her care. The licensee verified that no eviction letter had been issued. Based on the Licensee's admission that the resident is not being permitted to return and Licensee's admission that no eviction letter was issued the preponderance of evidence standard has been met and the allegation of illegal eviction is SUBSTANTIATED. Continued on LIC 9099C... Substantiated Deficiencies are being cited today from the California Code of Regulations (CCRs) Title 22, Division 6, Chapter 8. A civil penalty in the amount of $250 is also being assessed for repeat violations. An exit interview was conducted and a copy of this report and appeal rights were provided to Licensee.the state’s words, verbatim · CDSS document, Aug 15, 2022 · control 27-AS-20220804090523

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Aug 17, 2022

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required... This requirement was not met as evidenced by: Based on the interview with Licensee and the Licensee's admission that the POA was informed that R1 cannot return to the facility and the Licensee's confirmation that no eviction notice was served. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2022

Plan of correction: The Licensee agrees to submit via email a written attestation indicating that the regulation was read, understood and will be obliged by to maja.jensen@dss.ca.gov

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) T. White arrived at this facility unannounced to conduct a case management visit. LPA met with Caregiver, Elenor Laurora explained the purpose of the visit. LPA conducted a tour of the facility and observed the facility is in compliance. No deficiencies cited during inspection. Exit interview conducted with care staff and a copy of report given.the state’s words, verbatim · CDSS document, Mar 10, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA met with care staff and later with Administrator Expectacio Vierra and explained the purpose of the visit. Administrator's Certification # 6002286740 expires 4/12/23. LPA Jacobs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside yard of the facility to ensure compliance with Title 22 regulations. Facility is an 18-bed facility with a current census of 15. Facility has 9 shared bedrooms. There is an entry way and small lobby area. Facility has a separate dining room and activities room. Facility also has a hair salon and outside courtyard area for visitations. LPA also conducted the infection control domain tool. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Water temperature reads 112.5 F in the bathroom. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 4/20/21.FAcility has a built in sprinkler and smoke and heat detectors. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Expectacio Vierra.the state’s words, verbatim · CDSS document, Mar 4, 2022

Type of visit: Case Management - Deficiencies

On 10/14/2021 at 1:20pm, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced case management to conduct a follow up on an incident report submitted to the Department. LPA was allowed entry into the facility, met with Administrator, and and explained the purpose of today’s visit. Census 13. During the course of the investigation, LPA conducted interviews and reviewed records. Interviews and records review conclude Resident one (R1) moved in and on third day of admission, responsible party was advised R1 to be moved out and R1 was picked up the same day. Report stated staff are not trained to provide the appropriate level of care of R1's known behaviors prior to admission. The did not issue a 60 day eviction letter to Resident one (R1's) responsible party. Licensee did not send a 3-day eviction letter request to CCLD for approval. Per California Code of Regulations (CCRs) - Title 22, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.the state’s words, verbatim · CDSS document, Oct 14, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Oct 29, 2021

Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)..notice to the resident is required except as otherwise specified in paragraph (5) This requirement is not met as evidence by: Based on records review and interview the licensee did not comply with the section cited above in that R1 was evicted from the facility without written notice which poses a potential health, safety, and personal rights risk to person's in care.the state’s words, verbatim · CDSS document, Oct 14, 2021

Plan of correction: Licensee agrees to submit a plan of correction to LPA by POC due date how the facility will maintain compliance with the regulation at all times.

Type of visit: Case Management - Incident

On 09/22/2021 at 2:00pm, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a case management visit on an incident report submitted to the Department and explained the purpose of today’s visit. LPA was allowed entry into the facility and met with Designated staff (S1) and Administrator was unable to be present during today's visit. Census 12. On 9/20/2021 LPA received incident report for Resident one (R1) moving out the facility. LPA conducted interviews and requested records. At this time additional information is needed. LPA will return at a later date to conclude the investigation of the incident. Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held and a copy of report provided.the state’s words, verbatim · CDSS document, Sep 22, 2021

Type of visit: Required - 1 Year

On 8/26/21 at 1:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Expectacio Vierra and explained the purpose of the visit. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside yard of the facility to ensure compliance with Title 22 regulations. Facility is an 18-bed facility with a current census of 11. Facility has 9 shared bedrooms. There is an entry way and small lobby area. Facility has a separate dining room and activities room. Facility also has a hair salon not currently in operation. There is an outside courtyard area for visitations. LPA also conducted the infection control domain tool. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Water temperature reads 110.1*F in the bathroom and room temperature reads 76*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 4/20/21. Facility has an emergency food and water kit. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Expectacio Vierra.the state’s words, verbatim · CDSS document, Aug 26, 2021