C.A.L.L.-Carmelita House

Allegation investigated: Facility staff are not qualified. Facility does not have an administrator. Facility staff are not ensuring that residents attend their appointments.

On 10/23/2023 at 9:00am, Licensing Program Analyst (LPA) Jeffries conducted an unannounced follow-up visit to deliver final findings on the original complaint dated 6/22/2023. LPA met with Intin Adminstrator Valerie Braisher-King and explained the purpose of the visit. On the allegations, “Facility staff are not qualified” and “Facility does not have an administrator,” the complainant’s concern was that the facility’s administrator left on 6/20/2023 and there was no replacement or backup lead staff in place. LPA interviewed staff who indicated the licensee’s president was at the facility on 6/20/2023 and the Office Manager was at the facility on 6/21/2023 to help with medications. During LPA Chavez visit on 6/23/2023, LPA Chavez notified the facility they would need a replacement administrator, and the Office Manager indicated they were preparing the paperwork for another administrator to take over. LPA Chavez received the paperwork and updated the administrator on record. CONTINUED on LIC9099-C Unsubstantiated The facility also had two other administrators of the licensee’s other facilities designated as on-call administrators. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. On the allegation, “Facility staff are not ensuring that residents attend to their appointments,” the complainant’s concern was that because there was no administrator, the residents missed appointments. LPA Chavez interviewed Office Manager on 6/23/23. Office manager showed LPA Chavez a desk calendar with appointments. The calendar showed Resident 1 (R1) has an appointment on 6/28/23. The Office Manager stated she was trying to figure out where things were after the former administrator left on 6/20/23, and believed the appointments scheduled were on the desk calendar. However, no one was able to access the former administrator’s work cell phone, which could have appointments in it, but this was not confirmed. LPA Jeffries interviewed S6 who was working during the time of complaint, and confirmed no appointments were missed. LPA Jeffries could not find any documentation indicating appointments were missed. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview, report given.the state’s words, verbatim · CDSS document, Oct 23, 2023 · control 29-AS-20230622164857

Type of visit: Required - 1 Year

At 9:00am on 10/23/2023, Licensing Program Analyst (LPA) Mark Jeffries arrived at facility for an unannounced annual inspection visit. LPA met with Intern Administrator Valerie Braisher-King. LPA toured facility with Administrator. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning throughout the facility. Fire extinguishers were fully charged. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 73 degrees F. Hot water temperature tested and read within regulation requirements. Residents’ rooms are appropriately furnished with adequate lighting, storage and bedding. LPA observed more than two days of perishable and more than seven days of non-perishable food. Food is stored in proper containers in the refrigerator and freezer. A written disaster and mass casualty plan is readily available located on the facility office. LPA reviewed medications and conducted a sample medication audit.. Medications are stored in a locked cabinet in the staff storage room. There is a signed and dated order from a physician for prescription and PRN medication. LPA observed the medication administration record (MAR) and medications are given per physician's orders. Intern Administrator and LPA conducted a full review of the annual care tools. There was one technical violation noted on documentation of quarterly fire drill. Intern Administrator to conduct drill today (10/23/2023) to maintain regulation compliance. No other technical, citation, or deficiencies were noted on the full annual care tools review. Exit interview, no deficiencies or citations issued, report given.the state’s words, verbatim · CDSS document, Oct 23, 2023

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff did not follow resident's special diet

Licensing Program Analyst (LPA) Chavez conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial complaint visit was conducted on 08/03/2022 by LPA Chavez. During today’s visit, LPA met with Brenda Victoria, Administrator, and explained the reason for the visit. On 08/02/2022, the Department received a complaint regarding an allegation of Staff did not follow resident's special diet. It was alleged that staff did not follow Client #1 (C1’s) special diet plan when they took C1 to the fair on 07/25/2022 and allowed C1 to have food and drink which was not pureed or thickened, as was prescribed. On 08/03/2022, the Department referred the complaint to the Community Care Licensing Investigations Branch (IB) and Special Investigator Assistant Monica Lopez, was assigned to obtain a death certificate, medical records and hospice records. On 08/29/2022, the complaint referral was upgraded to a full investigation and was assigned to Investigator Romelia Munoz to investigate the allegations of questionable death and staff not following C1’s special diet plan. Continued on 9099-C. Substantiated On 08/03/2022, between 12:22pm and 3:30pm, LPA Chavez conducted an unannounced 24-hour complaint visit. The LPA met with Brenda Victoria, Administrator, and informed the reason for the visit. During the visit, the LPA interviewed the Administrator, reviewed records and obtained pertinent copies of facility records. LPA explained that further investigation was needed. The Administrator was notified that the case was referred to Community Care Licensing Investigation's Branch (IB) for further investigation. Investigator Munoz conducted interviews on 09/26/2022, at approximately 10:47am, with facility staff; on 09/27/2022, at approximately 9:32am, with C1’s primary medical doctor; on 10/18/2022, from approximately 9:45am to 12:45pm, with the Administrator and staff; on 11/10/2022, at approximately 2:50pm, with staff; on 11/14/2022, at approximately 9:00am, with staff; and on 11/15/2022, at approximately 9:45am, with C1’s resident representative. Additionally, the Investigator reviewed copies of Twin Cities Community Hospital medical records, Central Coast Hospice records and facility documents related to C1. The physician report dated 06/04/2021 lists C1’s diagnoses as Developmental Delay, Autism, and special diet pureed with thickened liquids. C1’s Individual Service Plan (ISP) dated 05/11/2022, also indicates C1 is dysphagic and requires a pureed, level II dysphagic diet. The investigation revealed that on 07/25/2022, Staff #1 (S1) took C1 to the fair. S1 allowed C1 to drink soda without Thick It powder and have a few bites of non-pureed hot dog. The soda and food were not thickened or pureed, as was prescribed by the doctor due to C1’s dysphagia. On 07/26/2022, at 11:38am, C1 began making gurgling sounds, vomited, and was sent to the Emergency Room. C1 was discharged the same day with a diagnosis of possible viral gastritis and prescribed nausea medication. Continued on 9099-C. On 07/27/2022, at 11:49am, C1 returned to the hospital for ongoing vomiting and difficulty breathing. C1 had low oxygen saturations and coarse breath sounds. C1’s x-ray showed slight haziness to the right upper lung. The doctors discussed the patient plan with C1’s resident representative who requested C1 be placed on comfort care. On 07/30/2022, C1 was discharged back to the facility on hospice care. C1’s discharge diagnoses included acute hypoxic respiratory failure, aspiration pneumonitis, seizure disorder, developmental delay and comfort care. C1 was placed on Central Coast Hospice care at the facility with the diagnosis of acute hypoxemic respiratory failure. On 07/31/2022, at 10:20pm, C1 stopped breathing and became unresponsive. Staff contacted the hospice nurse to report the death. Copies of C1’s service plan and facility demographic sheet stated C1 was a severe choking hazard and C1 is dysphagic which required C1 to be on a pureed diet. All staff interviewed had knowledge of C1’s pureed diet plan. However, multiple staff confirmed that C1 had a bite of a non-pureed hot dog and sips of soda while at the fair on 07/25/2022. The administrator stated that the staff also gave C1 a dime size pieces of funnel cake and did not bring C1’s Thick It powder to the fair. Based on the statements provided and documentation obtained, the Department has sufficient evidence to support the allegation Staff did not follow resident's special diet. Therefore, the allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report emailed to the executive director and administrator. On 08/03/2022, between 12:22pm and 3:30pm, LPA Chavez conducted an unannounced 24-hour complaint visit. The LPA met with Brenda Victoria, Administrator, and informed the reason for the visit. During the visit, the LPA interviewed the Administrator, reviewed records and obtained pertinent copies of facility records. LPA explained that further investigation was needed. The Administrator was notified that the case was referred to Community Care Licensing Investigation's Branch (IB) for further investigation. Investigator Munoz conducted interviews on 09/26/2022, at approximately 10:47am, with facility staff; on 09/27/2022, at approximately 9:32am, with C1’s primary medical doctor; on 10/18/2022, from approximately 9:45am to 12:45pm, with the Administrator and staff; on 11/10/2022, at approximately 2:50pm, with staff; on 11/14/2022, at approximately 9:00am, with staff; and on 11/15/2022, at approximately 9:45am, with C1’s resident representative. Additionally, the Investigator reviewed copies of Twin Cities Community Hospital medical records, Central Coast Hospice records and facility documents related to C1. The physician report dated 06/04/2021 lists C1’s diagnoses as Developmental Delay, Autism, and special diet pureed with thickened liquids. C1’s Individual Service Plan (ISP) dated 05/11/2022, also indicates C1 is dysphagic and requires a pureed, level II dysphagic diet. The investigation revealed that on 07/25/2022, Staff #1 (S1) took C1 to the fair. S1 allowed C1 to drink soda without Thick It powder and have a few bites of non-pureed hot dog. The soda and food were not thickened or pureed, as was prescribed by the doctor due to C1’s dysphagia. On 07/26/2022, at 11:38am, C1 began making gurgling sounds, vomited, and was sent to the Emergency Room. C1 was discharged the same day with a diagnosis of possible viral gastritis and prescribed nausea medication. Continued on 9099-C. On 07/27/2022, at 11:49am, C1 returned to the hospital for ongoing vomiting and difficulty breathing. C1 had low oxygen saturations and coarse breath sounds. C1’s x-ray showed slight haziness to the right upper lung. The doctors discussed the patient plan with C1’s resident representative who requested C1 be placed on comfort care. On 07/30/2022, C1 was discharged back to the facility on hospice care. C1’s discharge diagnoses included acute hypoxic respiratory failure, aspiration pneumonitis, seizure disorder, developmental delay and comfort care. C1 was placed on Central Coast Hospice care at the facility with the diagnosis of acute hypoxemic respiratory failure. On 07/31/2022, at 10:20pm, C1 stopped breathing and became unresponsive. Staff contacted the hospice nurse to report the death. C1’s death certificate listed the immediate cause of death as acute hypoxic respiratory failure with conditions leading to the cause of death as aspiration pneumonia and oropharyngeal dysphagia. The Twin Cities Community Hospital records noted C1 was initially seen for nausea and vomiting. C1 was discharged and later returned for continued vomiting and trouble breathing. C1 was diagnosed with acute hypoxic respiratory failure and aspiration pneumonitis, likely caused by ongoing vomit. C1’s primary medical doctor stated Thick It mix was prescribed to assist C1 with food texture due to swallowing difficulty and it was to be taken as directed. The doctor stated that there is a possibility that if staff gave C1 a drink without the Thick It, C1 could have developed a cough and it may have contributed, but he did not believe this would have been the cause of death. Based on the statements provided and documentation obtained, the Department does not have sufficient evidence to support the allegation Questionable Death. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report emailed to the executive director and administrator.the state’s words, verbatim · CDSS document, Dec 22, 2022 · control 29-AS-20220802165129

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 23, 2022

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents…shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. On 07/25/2022, staff did not follow C1’s special diet plan by giving C1 soda without Thick It powder and a non-pureed hot dog, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2022

Plan of correction: Licensee will submit a plan to ensure that staff have ongoing training in following individual resident diet plans and submit the plan to CCL by 12/23/22.

Allegation investigated: Staff not providing adequate supervision to resident in care.

On 10/06/22 at 10:35 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced complaint visit to deliver final findings to the facility listed above. LPA met with Susan Samayoa, Lead Caregiver, and explained the purpose of the visit. On the allegation “Staff not providing adequate supervision to resident in care,” the complainant’s concern was that Resident #1 (R1) was observed slumped over in their wheelchair for at least 30 minutes and staff did not help.” To investigate the allegation, LPA interviewed the supervisor, staff, and credible witnesses, and made observations. On 11/05/21 at 12:19 pm and on 9/29/22 at 12:25 pm, LPA interviewed Brenda Victoria, Supervisor. Supervisor states that resident R1 was in the hospital for 2-3 months prior to being admitted to the facility. Supervisor explains “R1 had a lot of medical problems and slumped in their chair at times due to multiple medical issues.” Supervisor says that staff would sit R1 up, and R1 would slump again. Continued on 9099-C. Unsubstantiated On 9/29/22 at 12:03 pm, LPA visited the facility and observed three staff caring for four residents. Staff assisted residents with lunch and cleaning-up after lunch. Residents appeared to be taken care of by staff who assisted with their needs. On 9/29/22 at 12:16 pm, LPA interviewed Staff #1 (S1). S1 says that there are always three staff working in the facility when all residents are present. S1 says that when R1 was in the facility, S1 witnessed “R1 leaning in their chair sometimes and staff and I propped R1 up with pillows.” At 12:47 pm, LPA interviewed Staff #2 (S2). S2 says that most of the time, R1 was in pain and sometimes R1 was in a wheelchair, sometimes in bed. S2 explains that R1 was weak and leaned in their wheelchair or recliner. S2 says they placed pillows to prop R1 up. A 12:55 pm, LPA interviewed Staff #3 (S3). S3 says that sometimes R1 was in a wheelchair and other times in bed or a recliner. S3 says R1 was “losing balance and leaning in the chair.” S3 says when R1 leaned in the chair, S3 and staff put pillows behind or beside R1 to hold R1 up. S3 says they sat, most times, in the living room watching over residents in addition to checking on them at least every 20-30 minutes. At 1:14 pm, LPA interviewed Staff #4 (S4). S4 says R1’s health went up and down and that “R1 sometimes was sliding out of the chair, then I would prop R1 up, then place pillows on R1’s side(s).” S4 says that R1 was more stable in the recliner and didn’t lean as much. On 9/30/22 at 11:24 am, LPA spoke with a credible Witness #1 (W1). W1 says they visited the facility in December of 2021 and did not witness R1 slumped in their chair nor did W1 notice anything out of the ordinary. On 10/05/22 at 3:22 pm, LPA spoke with a credible Witness #2 (W2). W2 states that the times they have gone to the facility, the facility had adequate staffing, staff appeared engaged and helping and in a couple cases over-staffed. W2 says “I do not see the staff sitting around talking, they are not on their cell phones. I think it is a very demanding and hands-on environment.” Based on the evidence obtained, the allegation “Staff not providing adequate supervision to resident in care,” is deemed Unsubstantiated at this time. Interviews and observations reveal that staff are assisting residents’ needs and in a timely manner. Exit interview conducted and a copy of the report emailed to the Executive Director and Supervisor.the state’s words, verbatim · CDSS document, Oct 6, 2022 · control 29-AS-20211103102612

Type of visit: Required - 1 Year

On 10/06/22 at 10:15 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility listed above. LPA met with Staff #1 (S1) and explained the purpose of the visit. At 10:45 am, Susan Samayoa, Lead Caregiver, arrived at the facility, and LPA and explained the purpose of the visit. LPA toured the facility with S1 and observed the following: The facility has soap and paper towels for residents’ bathrooms and handwashing signage. The fire extinguishers (two) are located in the hallway near resident bedrooms and the kitchen. The extinguishers are fully charged and were inspected on 11/08/21. The facility has infection control signage at the front door and signage throughout the facility on handwashing, cough etiquette and use of masks. Upon entry to the facility, LPA was screened. Staff were wearing masks. CDSS Provider Information Notices (PINs) were not readily accessible. Lead Caregiver will ensure these are made available in an accessible location for residents and staff. Lead Caregiver will send LPA a photo by 10/13/22. At 10:55 am, LPA conducted the Infection Control mitigation module with the Lead Caregiver. No deficiencies cited. Exit interview conducted and the report emailed to the Executive Director and Supervisor.the state’s words, verbatim · CDSS document, Oct 6, 2022

Allegation investigated: Facility failed to notify resident's authorized representative of incident.

At 2:00pm on 05/20/2022, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to deliver final findings of the complaint investigation. LPA met with House Manager Brenda Victoria and explained the purpose of the visit. LPA De Leon conducted the initial visit and requested documentation on 04/27/2021. LPA De Leon received and reviewed documentation on 04/28/2021. LPA De Leon received additional medical records from Twin Cities Hospital on 03/30/2022. LPA conducted interviews with witnesses on 04/26/2021 at 2:57 PM, 04/28/2021 at 2:37 PM, 04/28/2021 at 2:41 PM, 04/29/2022 at 3:30 PM, and on 05/18/2022 at 3:09 PM. LPA interviewed staff on 05/19/2022 at 3:13 PM, 3:40 PM, 3:58 PM and 4:10 PM. LPA thoroughly reviewed records on 05/19/2022 at 4:15pm. CONTINUED on LIC9099-C Substantiated On the allegation: Facility failed to notify resident's authorized representative of incident. LPA conducted interviews with staff and Resident 1 (R1)’s responsible parties. LPA also reviewed facility records including incident reports. The investigation revealed that R1 had responsible parties to contact after an incident, and documentation does not reveal all parties were contacted regarding R1’s fall incident on 2/23/2021. Therefore, the allegation is deemed Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Administrator/Licensee. On the allegation: Due to staff neglect, resident sustained fracture while in care. LPA interviewed witnesses, staff and reviewed medical records and incident report which revealed Resident 1 (R1) had a fall on 2/23/2021. Facility supervisor was immediately notified and R1 was take to the Emergency Room, where R1 was diagnosed with Intertrochanteric fracture of the right hip and scheduled for surgery the next day. No evidence was found during the investigation to suggest that staff neglected the resident, resulting in a fall. Staff sought immediate medical treatment for R1 when the fall occurred. Therefore, the allegation is deemed Unsubstantiated at the time. Exit interview conducted and copy of report emailed to Administrator/Licensee.the state’s words, verbatim · CDSS document, May 20, 2022 · control 29-AS-20210426110427

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: May 27, 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:(8)To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by: Based on witness interviews and documentation the Licensee did not comply with the regulation above and did not notify R1’s representatives of R1’s fall which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 20, 2022

Plan of correction: Administrator updated resident identification and emergency information records to include all residents contacts to notify. Administrator agreed to train staff on 87468.1 personal rights and incident reporting requirements, send copy of training with staff signatures to CCL.

Allegation investigated: Staff yell at residents.

On 4/13/2022 at 3:52 pm, Licensing Program Analyst (LPA) Chavez initiated an unannounced complaint visit to discuss the final findings for the allegation listed above. LPA met with Regina Ceasar, Administrator for C.A.L.L. /Day Program and explained the reason for the visit. Regarding the allegation, “Staff yell at residents,” the complainant was concerned that Staff #1 (S1) yelled at Resident #1 (R1) on 10/21/21. Complainant states that S1 was assisting R1 with applying deodorant, and R1 would not lift R1’s arm. Further, that S1 said to R1 “Why are you fighting with me? Stop fighting with me?” To investigate the allegation, LPA interviewed staff and reviewed records. Continued on 9099-C. Substantiated On 10/28/21 at 12:17 pm, LPA interviewed S3. S3 stated that “Two weeks ago, S1 was yelling at clients to ‘sit here and eat your food,” and S3 told the supervisor. On 10/28/21 at 12:31 pm, LPA inquired with S4. S4 describes S1 as “new to the job, one year” and that S1 “has said loudly to clients ‘eat your breakfast, take your toothbrush,” in a frustrated tone. S4 mentioned the incident to the supervisor. On 10/28/21 at 12:51 pm, LPA spoke with S5 who explains that S1 has a high tone and S5 has had to remind S1 how to talk with residents. S5 said S1 has gotten frustrated and S5 has talked with S1 five times and written-up S1 once. S5 says S1 is no longer employed with the facility effective 10/25/21. On 11/02/21 at 9:00 am, LPA inquired with S6. S6 expresses that S6 recalls seeing S1 “forcing Resident #2’s (R2) head back, cursing and yelling at R2.” S6 states they spoke with the supervisor a few weeks prior regarding S1’s being “rough with clients.” On 11/04/21 at 1:15 pm, a credible Witness #1 (W1) asked S1 if S1 ever gets frustrated or pushes S1’s patience, and S1 replied “No, it’s not their fault.” LPA asked S1 if S1 has ever seen other staff yell or get rough with residents, and S1 says they have not heard anyone yell at residents and as far as getting rough, S1 says “No, I would report it to the supervisor.” On 4/13/22, LPA reviewed facility records. Records indicate that S1 was counseled and written up for acting inappropriately with residents in care. Based on interviews, the allegation that “Staff yell at residents,” is deemed Substantiated at this time. Interviews with staff show that S1 has been observed speaking to residents in a loud, frustrated tone. S1 has also been counseled on this behavior. A copy of the report, deficiency, and appeal rights emailed to the administrator. On 10/22/21 at 1:12 pm, LPA interviewed Staff #2 (S2). S2 says that R1 was “taken to the hospital this morning” due to a bruise on R1’s right upper arm between the elbow and shoulder on the under part of the arm. S2 says R1 “has a bruise 8 inches long and 4 inches wide, and it is swollen.” S2 says R1 bruises easily because R1 is anemic. S2 informed the supervisor about the bruising on 10/21/21 at 6:30 pm when S2 noticed it while giving R1 an evening shower. S2 described the bruise as “purple-blueish, a rich purple color” and said it was a new bruise. S2 explained that R1 is “nonverbal, but makes noises to communicate.” S2 asked R1 if it hurt, and R1 responded by nodding “yes.” On 10/28/21 at 12:17 pm, LPA interviewed Staff #3 (S3). S3 says that on 10/21/21, at 2:45 pm, S3 changed R1’s shirt and did not see any markings on R1’s right upper arm underside. S3 says on 10/22/21 at 6:50 am, S3 looked at R1’s arm and “knew it was cellulitis, not a bruise.” On 10/28/21 at 12:31 pm, LPA interviewed Staff #4 (S4). S4 says that on Friday morning, 10/22/21, S4 saw the marks on R1’s arm and “did not know what the marks are.” On 10/28/21 at 12:51 pm, LPA interviewed Staff #5 (S5). S5 said that on Thursday, 10/21/21 between 7:00 pm and 8:00 pm, S2 called S5 and informed that R1 had a “rash, bruising on the arm”, but showed no signs of pain. On Friday morning, 10/22/21, S5 says they took R1 to the ER and told ER staff that R1 has “an arm injury and rash.” S5 says S5 thought it might be a bruise as it was swollen. S5 said the hospital gave R1 a 10-day antibiotic and “immediately the bruising went away.” On 11/04/21 at 1:00 pm, LPA spoke with S1. S1 says S1 has never been aggressive with residents and didn’t think it was a bruise on R1’s arm, but rather that “it looked like cellulitis” and described it as looking “red, swollen, hot to the touch, and about 6-7 inches under the arm to elbow.” On 4/04/22 at 5:00 pm, LPA reviewed hospital records for R1’s visit on 10/22/21. On 10/22/21 at 9:50 am, R1 was seen at the hospital for “redness, bruising and pain to the right upper arm.” The hospital visit summary states “unknown if it is an injury.” The diagnosis was listed was an arm injury, Cellulitis, and Hyponatremia. The ER physician notes that the right upper arm has tenderness, bruising and redness, no wounds. R1 was given an antibiotic and prescribed an antibacterial medication. LPA reviewed photos taken by staff of R1’s right upper arm. Continued on 9099-C. LPA reviewed photos taken by staff of R1’s right upper arm. LPA reviewed the photos and observed that on 10/22/21, R1 had a red sporadic marking on the upper inside arm with a length of about seven inches and a width of approximately four inches. In the crease of R1’s arm on the opposite side of the elbow, there was a gray patch approximately three inches by three inches. In the 10/25/21 photo, R1’s upper inside arm shows dark pink coloring in four patches from the shoulder to the elbow. In the 11/01/21 photo, there is a patch of pale redness near the elbow under the arm. The bruising is no longer visible. Based on the evidence obtained, the allegation that “Staff caused injury to resident” is deemed Unsubstantiated at this time. R1 had markings on their upper inside right arm, however, it is not clear that the bruising and redness was caused by staff. R1 had a sensitivity for bruising and history of cellulitis. On the allegation “Staff handled residents in a rough manner,” the complainant’s concern was that R1 was being mishandled by S1. Complainant stated that staff observed S1 being rough with R1 on 10/21/21, and that staff witnessed S1 attempting to “force” R1’s arm to put deodorant on R1. To investigate the allegation, LPA interviewed the complainant and staff, and attempted to interview resident. LPA interviewed S1, S2, S3, S4, and S5 from 10/22/21 through 11/04/21. Interviews reveal that staff did not observe the incident and have not seen any staff handle residents in a rough manner. On 10/28/21 at 1:20 pm, LPA attempted to interview R1, however, R1 was nonverbal. Based on interviews, the allegation “Staff handled residents in a rough manner,” is Unsubstantiated at this time. The testimony given by the staff shows that staff do not mishandle residents. Regarding the allegation “Staff do not report incidents,” the complainant was concerned that there was an incident on 10/21/21 that was not reported by S1. To investigate the allegation, LPA reviewed facility records and interviewed staff. On 10/23/21 at 11:12 am, CCL received an incident report from the facility reporting that, “On 10/21 during R1’s PM shower staff noticed a red rash with some bruising on R1’s upper inner arm of approximately 8 inches in length and 4 inches in width, it was hot to the touch. In the morning symptoms were worsening.” The report states R1 was taken to the emergency room and the diagnosis was cellulitis. Continued on 9099-C,. On 10/28/21 at 12:17 pm, LPA spoke with S3 who stated that when an incident occurs at the facility, S3 writes an incident report and gives it to the supervisor. On 11/02/21 at 9:00 am, LPA interviewed S6 who said S6 has not seen or heard of S1 creating incident reports and had not seen one for the situation on 10/21/21 with R1. On 11/04/21 at 1:00 pm, LPA spoke with S1 who stated that S1 “has filled out incidents reports” and recalls “twice, once when a resident fell, and I don’t remember the other time.” On 4/12/22 at 11:39 am, LPA reviewed incident reports submitted by staff and reported to CCL. Between 7/1/21 and 10/31/21, staff submitted four incident reports to management. Between 1/11/21 and 11/04/21, the facility sent fourteen incident reports to CCL. Records show that staff did not submit an incident report for the incident on 10/21/21; however, management did report the incident to CCL. Based on interviews and record review, the allegation that “Staff do not report incidents,” is deemed Unsubstantiated at this time. Staff interviews reveal that staff are expected to complete incident reports as part of their job. Records review indicates that incidents reports are being written and sent to CCL. Regarding the allegation, “Resident's dental needs are not being met,” the complainant was concerned that Resident #3 (R3) had chipped and jagged teeth that were “stubs.” The complainant showed concern that R3 was in pain and states that when staff try to brush R3’s teeth, R3 kicks them or tries to run away. To investigate the allegation, LPA reviewed records and interviewed staff and witnesses. On 4/12/22 at 11:02 am, LPA reviewed R3’s dental records. Records indicate that a dental hygienist went to the facility on 5/07/21 to perform an oral evaluation and dental cleaning. Hygienist records show that R3 has “no visible cavities” and recommended R3 see a doctor at the next “annual” exam. On 9/25/21, a hygienist visited R3 at the facility again and documented that R3 had a cavity and recommended that R3 see a dentist “ASAP.” On 4/02/22, R3 was seen again by a hygienist at the facility. The hygienist applied silver diamine fluoride (SDF) to stop the decay, noted that a second tooth had a cavity, and recommended R3 see a dentist at the next “annual exam.” Facility records indicate that R3’s most recent dental exam occurred on 2/11/20. On 4/12/22 at 2:04 pm, LPA spoke with Witnesses #2 and #3 (W2 and W3) who confirmed that dental hygienists visited the facility on 5/07/21, 9/25/21 and 4/02/22 to conduct an oral evaluation and dental cleaning on R3. They clarified that the hygienist does a visual evaluation and there are no x-rays. W1and W2 explained that during the pandemic, dentists were not seeing patients and that now, dentists are backed-up with patients. They also stated that there are only two dentists in the area that work with “this population” because the residents have a hard time with examinations and procedures, and many times have to be placed under anesthesia. Continued on 9099-C. On 4/12/22 at 4:01 pm, LPA spoke with S5 who stated that S5 contacted a dentist on 11/23/21 to make an appointment for R3. The dentist would not see R3 due to R3’s age. The dentist’s office stated “it would be too much of a liability to put R3 under sedation.” On 4/12/22, S5 called R3’s dentist again, and R3 is scheduled for a consultation in July 2022. Based on evidence obtained, the allegation, “Resident's dental needs are not being met,” is deemed Unsubstantiated at this time. Due to the pandemic, facility staff were unable to schedule a dental appointment for R3, yet R3 was seen three times in the past year by dental hygienists. The facility took appropriate measures to address R3’s dental needs by having hygienists evaluate and provide cleanings. Regarding the allegation, “Residents do not receive PRN in a timely manner,” the complainant showed concern that staff did not receive a timely response when phoning a supervisor to get approval to give PRNs to residents. Complainant stated that R1 often screams and that staff tried several times to get a hold of the supervisor. Complainant said R1 had to wait two hours for PRNs because the supervisor did not respond in a timely manner. To investigate the allegation, LPA interviewed staff. On 10/28/21 at 12:17 pm, LPA Chavez interviewed S3 who stated that the procedure for when a client needs a PRN is that S3 calls the supervisor for permission. S3 says the supervisor responds “usually within two to three minutes.” S3 said if the supervisor doesn’t respond, S3 calls the Lead. On 10/28/21 at 12:31 pm, LPA Chavez conversed with S4 who relayed that S4 observes residents’ needs and calls the supervisor, if a client needs a PRN.” On 11/04/21 at 1:00 pm, S1 said that when a resident needs a PRN, S1 evaluates the behavior to see if they’re agitated or anxious, and if so, for more than 20-30 minutes, S1 notifies the supervisor and explains the behavior. S1 said “most times, the supervisor responds instantly.” S1 says occasionally S1 will not get a response within “10-15 minutes” and then S1 texts the lead. S1 relays “this happened maybe once.” Based on the evidence obtained, the allegation, “Residents do not receive PRN in a timely manner,” is deemed Unsubstantiated at this time. Staff interviews reveal that the supervisor typically responds in a timely manner to staff requests for PRNs. When the supervisor is unavailable, a back-up lead is available. Exit interview conducted and a copy of report emailed to the administrator.the state’s words, verbatim · CDSS document, Apr 13, 2022 · control 29-AS-20211022094417

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 18, 2022

87468.1(a)(1) Personal Rights to Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not as evidenced by: Based on interviews and record review, the licensee did not ensure the personal rights of residents in care. S1 was speaking to residents in an unsafe manner which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 13, 2022

Plan of correction: Licensee has agreed to implement greater screening measures prior to hiring staff. Administrator will conduct training on Reg. 87468.1 Personal Rights of Residents in All Facilities with staff and send the sign-in training sheet to CCL by 4/18/22.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 02/25/2022 at 11:00 AM. LPA met with House Manager Brenda Victoria. Administrator was unable to met for visit. LPA explained the purpose of the visit. LPA took a physical plant tour of the facility with staff. The facility has submitted a mitigation plan to the department and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff, residents returning to the facility and visitors wanting to come into the facility. All documentation is kept on a clipboard and in binders. The entry station has hand sanitizer along with a thermometer. The facility has a living room to accommodate activities, a dining room for dining, all areas are spaced to accommodate as much space as possible for social distancing. The facility has a large covered for gazebo resident use. All equipment and PPE supplies are kept in the staff office and in storage. Medications are kept in a locked medication cabinets in the staff area. The staff screen residents for symptoms and temperature 1x's a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area and walls in common areas regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Continued 809-C Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Executive Director/Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 5 resident bedrooms and 2 resident bathrooms and they are disinfected regularly. Enhanced precaution signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked staff office. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Fire extinguishers are charged and inspected annually. No deficiencies observed during the visit and all infection control protocols are implemented and are being followed. Exit interview completed and copy of report emailed to Administrator/Licensee.the state’s words, verbatim · CDSS document, Feb 25, 2022