RM Ugale Care Home

Type of visit: Required - 1 Year

On 10/16/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member (SM), Shamima Ali and explained the purpose of the visit. LPA asked that SM Ali call the Facility Designated Administrator (FDA), Maybelyn Ugale, and inform her that CCL was present at this time. Shortly after, LPA met with FDA Ugale and explained the purpose of the visit. There were two other staff members present at the facility, Cathleen Maghinay and Esterlita Chua. This facility is licensed to serve 6 residents who are 60 or older. 6 out 6 residents may be non-ambulatory. This facility also holds a Dementia Plan on file and has a hospice waiver for 2. Upon arrival at the facility, it was found that S1 was not currently associated to the facility. LPA asked to review staff and resident files. LPA was informed that staff did not know where files were, however, the facility administrator would be able to find the files when she arrives at the facility. LPA informed the facility that files shall be readily available upon request. LPA reviewed 3 resident files. 3 out of 3 resident files were observed not to have a current Appraisal form and did not have a Pre-Appraisal. 1 out 3 resident files did not have a current physicians report on file. LPA reviewed 3 staff files. 3 out 3 staff files were observed to be incomplete. Upon reviewing facility files, LPA observed FDA Ugale take several sharps from an open drawer and place them into a locked cabinet. The current administrator does not have a current active administrator certificate, however, the administrator has provided the department the proper renewal forms prior to their expiration date on 09/17/2023. The department reviewed a payment on 09/08/2023. A tour of the facility was conducted. A tour of the kitchen was conducted. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply at this time. Knives were locked and made inaccessible in a separate closet away from the kitchen at this time. A fire extinguisher located in the kitchen was observed to be last serviced on 06/15/2023 by Armor Fire Inc and is in compliance at this time. Smoke detectors and carbon monoxide was observed to be in good repair. Medication was observed to be in a locked cabinet near the kitchen. Along with the administrator, LPA reviewed and compared resident medication to medication dispensing logs. A tour of 3 resident bedrooms were conducted. LPA observed that in 2 out 3 resident bedrooms did not have a chest of drawers sufficient to meet the resident's needs. A tour of a staff bedroom was also conducted. A tour of 2 resident bathrooms were conducted. Hot water temperature was taken to ensure that it was dispensed at the correct temperature at this time. LPA osberved water damage on the corner of the baseboard near the shower. Additionally, scuffs from the resident's belongings were along the walls. A linen closet was identified. Linen was observed to be in sufficient for residents in care. A tour of the garage was conducted. Washer and dryer were identified. Toxins, laundry detergent and other cleaning supplies were observed to be locked and made inaccessible. A tour of the yard was conducted. Perimeter fence and gates were observed to be in good repair with no hazards present. Based on the observations made on this visit, an immediate civil penalty of $500 was assessed for a violation of Section 80019(e)(2). This civil penalty was based on criminal record clearance transfer violation. The Licensee stated that S1 and S2 was working prior to obtaining her criminal record clearance transfer and has not done the paperwork prior to working at this facility. As a result of this visit, the following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. An exit interview was conducted. A copy of the 809, 809-C, 809-D, LIC421BG and appeal rights were printed and a copy was given to the facility designated Administrator, Maybelyn Magsayo-Ugale. The licensee was informed that a failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.the state’s words, verbatim · CDSS document, Oct 16, 2023

Type of visit: Required - 1 Year

On 10/17/2022 at 10:15am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual infection control visit. LPA Pascua was greeted by staff member, Michael Gamboa and was asked to call the Administrator, Maybelyn Magsayo-Ugale to let her know that licensing was present at this time. Upon arrival the LPA observed a centralized screening point equipped with hand sanitizer and masks. Shortly after, LPA Pascua met with Administrator Ugale explained the purpose of the visit. The purpose of the visit is to conduct an annual infection control visit. This facility is licensed for 6 non-ambulatory residents and has a hospice waiver for 2. The administrator has an active certificate #6026752740 and expires on 09/17/2023. There were 4 other staff members present at this time, Michael Gamboa. Theresita Alvarez, Nora Casaverde, and Rosita Curilan. At 10:30am, LPA Pascua initiated a tour with Administrator Ugale. At 10:35am, LPA Pascua toured the laundry room and garage. Washer and Dryer were observed to be in good repair. A linen closet was identified in the garage and was observed to be a sufficient amount of linens for 6 residents at this time. LPA observed toxins, laundry detergent and other supplies to be in locked cabinets located in the garage and made inaccessible to the residents in care. At 10:45am, LPA Pascua toured the kitchen. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food supply. Kitchen cabinets, appliances, and sink were observed to be in good repair. LPA observed knives to be located in a closet located in the hallway next to the kitchen. A fire extinguisher located in the kitchen was observed to be serviced by a local fire company, Armor Fire Co. on 06/28/2022. At 10:50am, LPA Pascua toured the dining room and living room. Windows, blinds, and screens were in good repair. Furniture and furnishings intended for resident use were observed to be in maintained and in good repair. At 10:55am-11:10am, LPA Pascua toured 3 shared resident bedrooms. Resident furniture was observed to be sufficient to meet their needs at this time. At 11:15am, LPA toured two resident bathrooms. Hot water temperature was measured to be 112 degrees. Grab bars were observed to be stable and in good repair at this time. At 11:20am, LPA Pascua toured the live-in staff bedrooms and bathrooms. At 11:25am, LPA Pascua toured the exterior of the physical plant. Perimeter fence was observed to be stable and gates were in good repair. At 11:30-11:45 am, LPA Pascua observed a locked centralized stored medication cabinet located in the kitchen. Along with the Administrator Ugale, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. The following forms and documents were requested to be updated and submitted into CCL -LIC 308 -LIC 400 -LIC 500 -LIC 610 Based on the observations made on this visit, an immediate civil penalty of $1000 was assessed for a violation of Section 80019(e)(2). This civil penalty was based on criminal record clearance transfer violation. The Licensee stated that S1 and S2 was working prior to obtaining her criminal record clearance transfer and has not done the paperwork prior to working at this facility. As a result of this visit, the following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. An exit interview was conducted. A copy of the 809, 809-C, 809-D, LIC421BG and appeal rights were printed and a copy was given to the facility designated Administrator, Maybelyn Magsayo-Ugale. The licensee was informed that a failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.the state’s words, verbatim · CDSS document, Oct 17, 2022

Type of visit: POC

Licensing Program Analyst (LPA) Albert Johnson conducted a case management visit to check the POC deficiencies that were cited on 12/20/2021. LPA met with Staff (Romeo Constantino and Anges Pondoc), LPA toured the facility. LPA observed all deficiencies have been corrected. POC cleared on this date. No other deficiencies observed or cited. A copy of this report was left.the state’s words, verbatim · CDSS document, Mar 14, 2022

Allegation investigated: Facility staff did not make medications inaccessible to resident. Illegal eviction.

Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to RM Ugale to deliver the finding of the above allegation. LPA met with Mabelyn Magsayo-Ugale, Administrator. It was alleged that the facility staff did not make medications inaccessible to resident. Based on records reviewed and interviews conducted, the resident consumed medications that were in the residents possession when the resident was picked up from the hospital and brought back to the care home. The administrator stated the hospital was did not inform the staff that the resident had medication. The administrator stated the facility did not receive any forms from the placement agency and the hospital. The administrator stated the staff did not have any communication with the discharging nurse and did not confirm diagnosis or any medical follow-up. When the administrator and care staff brought the resident to the residents room, because they were not aware the resident had any medication, the resident was able to attempt to swallow pills which resulted in the facility having to call 911 and bring the resident back to the hospital. Therefore, the allegation that the facility staff did not make medications inaccessible to resident is substantiated. Substantiated 9099 Cont. >>>>>>>>>>>>>>>>> Based on records reviewed and interviews conducted, the resident consumed medications that were in the residents possession when the resident was picked up from the hospital and brought back to the care home. The administrator stated the hospital was did not inform the staff that the resident had medication. The administrator stated the facility did not receive any forms from the placement agency and the hospital. The administrator stated the staff did not have any communication with the discharging nurse and did not confirm diagnosis or any medical follow-up. When the administrator and care staff brought the resident to the residents room, because they were not aware the resident had any medication, the resident was able to attempt to swallow pills which resulted in the facility having to call 911 and bring the resident back to the hospital. Therefore, the allegation that the facility staff did not make medications inaccessible to resident is substantiated. The following deficiencies was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview conducted with ED, Teresa Pettapiece and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 20, 2021 · control 27-AS-20211124082023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Dec 21, 2021

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) 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 regulation was not met as evidence by based on the interviews conducted, the licensee did not ensure that resident did not have access to medication. Resident had medication in their purse and attempted to take the medication. This poses an immediate health and safety risks to resident in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licesnee will conduct a training with staff on process when accepting a new resident to ensure all belongings are accounted for and medications are locked. Licesnee will write a letter acknowleding understanding of regulation and submit to LPA by POC date.

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

87224 Eviction Procedures (b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself or to the mental and/or physical health or safety of others in the facility. This regulation was not met as evidence by based on the interviews conducted, the licensee did not ensure proper procedures and approval was recieved prior to not accepting the resident back into care. This poses a potential risks to resident in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licesnee will write a letter acknowleding understanding of regulation and submit to LPA by POC date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to RM Ugale for the purpose of opening a Case Management. LPA met with Mabelyn Magsayo-Ugale, Administrator. During records reviewed, LPA observed a resident admitted into the care home without the proper admission agreement completed and signed by the responsible party. The resident had no paperwork for emergency contacts. .LPA observed the resident did not have a physicians report or 602 prior to moving into the home. Interviews with care staff anf administrator conducted confirm the care staff and administrator had no understanding of the medical needs of the resident. The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview conducted with Mabelyn Magsayo-Ugale, Administrator and a copy of this report was provided.. .the state’s words, verbatim · CDSS document, Dec 20, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87458(a) · Plan of correction due date: Dec 21, 2021

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This regulation was not met as evidence by, licensee did not ensure to obntain an 602 or physcians reportt prior to accepting the resident. This poses an immediate risk to resident in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licesnee will write a letter acknowleding understanding of regulation and submit to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(a) · Plan of correction due date: Dec 29, 2021

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This regulation was not met as evidence by, licensee did not ensure to obntain an addmission agreement prior to accepting the resident. This poses an potential risk to resident in care.the state’s words, verbatim · CDSS document, Dec 20, 2021

Plan of correction: Licesnee will write a letter acknowleding understanding of regulation and submit to LPA by POC date.

Allegation investigated: Facility is not allowing resident to call family.

Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to RM Ugale to deliver the finding of the above allegation. LPA met with Mabelyn Magsayo-Ugale, Administrator. It was alleged that the facility is not allowing resident to call family. LPA toured the facility. LPA observed facility has multiple phones available to the residents. LPA observed a functional phone in both the living and kitchen areas. R1 stated the facility was not allowing R1 to call family. R1 wanted to make arrangements with R1s Responsible Party. R1s responsible parties are R1s immediate family members. R1 is requesting R1s responsible parties make arrangements to move R1 back home. Records reviewed and interviews conducted R1 has been in contact with Responsible Party. Interviews conducted confirm Responsible Party is aware of R1s request and in process of making arrangements. LPA observed that R1 also has full access to email. LPA conducted interviews with 3 residents. All 3 residents stated they had access to the phone. Based on information provided through interviews and records reviewed, these allegations are deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported. No deficiencies have been cited. Copy of the report provided to AD. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 12, 2021 · control 27-AS-20210830154657

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced Annual/ Infection Control visit on this date. LPA was greeted by caregiver, Andres Villaluz. (C1). LPA met with MAYBELYN MAGSAYO-UGALE, Administrator (AD). Administrator Certificate valid until 9/17/2021. LPA and C1 inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, laundry room, and dining room area. LPA observed sufficient seven days non-perishable and two days perishable food supplies in the main kitchen. LPA observed sharps and centrally stored medications locked in pantry closet. Hot water temperature was measured in residents' bathroom with C1 at 120 degrees which is in required range of 105 to 120 degrees. LPA observed there was a Carbon Monoxide/ Fire monitors in facility. Fire extinguisher maintained on 6/23/21. LPA reviewed 3 staff and 5 resident files. Resident files were incomplete. LPA observed missing preappraisals, incomplete emergency contact. All persons in facility fully vaccinated with exception to 1 staff due to personal reasons. LPA observed staff wearing masks. LPA observed 30 days PPE supply in laundry room. Upon entry, caregivers did not conduct symptom/temperature check until requested by LPA. No sanitizer or thermometer were observed. LPA observed no masks available to visitors. Sign in sheets were observed to document date and visitors name. Sign in sheets did not include symptom screening for reporting requirements to public health officer and contact tracing. LPA observed in oxygen for a resident on hospice. No Oxygen signs posted. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.the state’s words, verbatim · CDSS document, Sep 9, 2021

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Sep 20, 2021

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (1) Conduct an interview with the applicant and his responsible person. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above there were no pre-admission assessments or interviews which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2021

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Sep 20, 2021

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above there were no pre-admission assessments or interviews which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2021

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Sep 20, 2021

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (8) Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above there were no updated emergency contact information for each resident or information was missing which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2021

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Sep 20, 2021

87705 (I)(8) Care of Persons with Dementia. Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement was not met as evidenced by records reviewed, facility did not have record of fire Drill log. Caregiver. Licensee had no record to provide to LPA. LPA was unable to determine when the last disaster drill was conducted as required. This poses a potential safety risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2021

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Sep 10, 2021

87618 (b)(3)(B) Oxygen Administration - Gas and Liquid - Oxygen in Use signs shall be posted in appropriate areas. (As identified in 87101: (E) Maintenance of house rules for the protection of residents) This regulation was not met by evidence by: Based on observation, AD did not ensure posting of oxygen in use signs of the resident(s) rooms that had oxygen. This poses an immediate threat to the residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2021

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Sep 20, 2021

87464 (f) 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 regulation was not met by evidence by: A sign-in policy and PPE supplies available upon entry was not enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing).the state’s words, verbatim · CDSS document, Sep 9, 2021