Vista Rosa Elder Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Chavez made an unannounced Annual/Required visit to the facility above. LPA met with Administrator Jessica Bailey and Back-up administrator Rachelle Tellez and explained the purpose of the visit. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights on the hallway walls next to the staff office downstairs. The facility has 19 bedrooms and 22 bathrooms currently occupying 19 residents. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, all in good condition. The facility maintains a comfortable temperature. The dual smoke and carbon monoxide detectors are hard wired along with a sprinkler system and is operational. Fire extinguishers located next to the entrance of the elevator, upstairs and downstairs, and in the kitchen were inspected on 05/04/23 and are charged in the green. There are no issues with Fire Clearance. Living room, dining room, and activity room furniture were checked and in good condition. The common rooms are clean, safe and sanitary. The courtyard of the facility has outdoor furniture, with shaded area for residents. There are no bodies of water. The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Refrigerators are kept at 40 F or below and freezers at 0 F degrees. Continued on 809-C. Resident rooms are adequately dressed with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and sufficient lighting for each resident. Resident rooms #3 and #13 have “No smoking, oxygen in use” signage on their doors, and the same sign is at the front entrance of the facility. There is enough linen available to change weekly or more, if needed. The Storage room has sufficient amounts of personal hygiene product which is provided by the licensee and all cleaning products, toxins are stored and locked away inaccessible to residents in care. The bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 107.6 F and 111.17 F degrees in resident rooms 3, 6, 11, 13, and 17. Medications are centrally stored in the locked medication room behind the administrative office. Medications are properly labeled and checked for expiration dates. A sampling of resident’s medication show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. Proper medication dispensing instructions are followed and checked for contamination. First Aid has all proper items and is current. Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. There were no issues with resident files reviewed. Planned activities are offered to residents in care. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations/and current First Aid. The Administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate. All required training has been completed. Exit interview conducted, no deficiencies cited and report given.the state’s words, verbatim · CDSS document, May 4, 2023

Allegation investigated: Facility is not providing appropriate assistance for resident’s multiple falls. Facility did not observe changes in resident's physical health. Staff are not assisting resident with using hearing aids.

On 10/27/22 at 2:08 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced follow-up complaint investigation visit to the facility above to deliver final findings. LPA met with Jessica Bailey, Administrator, and explained the purpose of the visit. On the allegation, “Facility is not providing appropriate assistance for resident’s multiple falls,” the complainant was concerned that Resident #1 (R1) had fallen three times because R1 is reluctant to use their walker. The complainant states that the facility suggested putting a floor mat or increasing bed railing and states the facility has made some effort to accommodate R1’s sleeping pattern. LPA investigated by interviewing administrator, staff, resident, and witness, and reviewing records. On 12/29/21 at 12:47 pm, LPA interviewed R1. R1 says they don’t remember the last time they fell. Continued on 9099-C. Unsubstantiated On 12/29/21 at 11:18 am, LPA interviewed Staff #1 (S1). S1 states that, in November 2020, S1 spoke with R1’s POA regarding how to reduce falls. S1 implemented a chair alarm and placed a mat on the floor next to R1’s bed. S1 says R1 has had a bed alarm since move-in. S1 says that R1 did not have a walker at move-in in 2019. S1 says that R1’s doctor made evaluates after each fall and ordered physical therapy. S1 explains that “R1 forgets to use the walker which R1 began using after a fall in February 2021.” S1 says they discussed it with family, and family didn’t want bed rails and didn’t want R1 to go on hospice. S1 says that “R1 falls mostly at night time so I put a night light on.” On 10/24/22 at 10:57 am, LPA interviewed Witness #1 (W1). W1 says that “R1 had falls but the facility did everything they could.” W1 says R1 “did not fall that often, approximately once every few months” and expresses “they fall” when speaking about older adults. On 10/27/22 at 2:45 pm, LPA interviewed the administrator. Administrator states that R1 had a tendency to walk at night and sleep in the day. Administrator says that R1’s falls were due to R1 just waking up and not being alert and then R1 forgot to use their walker. On 10/27/22, LPA reviewed R1 records. On R1’s 2021 assessment, the facility states that “R1 ambulates with a walker, though sometimes R1 forgets, R1 isn’t upset when reminded to use it.” R1 has a dementia diagnosis. Based on evidence obtained, the allegation “Facility is not providing appropriate assistance for resident’s multiple falls,” is deemed Unsubstantiated at this time. Interviews indicate the facility made efforts to assist R1 with R1’s needs, and that R1’s dementia and night walking made R1 forgetful in using the walker. On the allegation “Facility did not observe changes in resident's physical health,” the complainant’s concern was that Resident #1 (R1) had “a skin sarcoma the size of a golf ball that went unnoticed until it was nearly inoperable.” To investigate, LPA interviewed the administrator and witness, and reviewed records. In LPA’s interview on 10/24/22 with W1, W1 states that R1’s growth was about the size of a quarter “earlier on before COVID.” W1 says it was brought it to the facility’s attention “sometime around the holidays 2020” and by that time, it had grown to the size of a half dollar and protruded out. W1 says the facility contacted R1’s doctor who looked at it. W1 says the facility “got on it right away and surgery was performed in April 2021.” Continued on 9099-C. On 10/24/22 at 11:57 am, LPA interviewed the administrator. Administrator states that Staff #1 (S1) reported the skin legion to R1’s doctor at the end of December 2020. Administrator spoke with doctor who states R1 had a growth that the doctor attempted to freeze, however, it was not successful in reducing the growth. On 10/27/22, LPA reviewed resident records. Records indicate that S1 contacted R1’s doctor on 12/9/2020 to inform of R1’s growth. In January 2021, the doctor attempted treat the lesion, in March 2021, R1 saw a dermatologist upon the doctor’s recommendation, and in April 2021, R1 had the growth excised. Based on the evidence obtained, the allegation “Facility did not observe changes in resident's physical health,” is deemed Unsubstantiated at this time. Interviews and documentation reveal that the facility observed and treated R1’s condition in a timely manner. On the allegation, “Staff are not assisting resident with using hearing aids,” the complainant was concerned that the facility refused to put R1’s hearing aids in during the day. Complainant relays that the facility is concerned the hearing aids will get lost but says that R1’s mental cognition and communication decreased due to not wearing the aids. To investigate the allegation, LPA interviewed staff, resident, and witness. When LPA spoke with R1 on 12/29/21, R1 says that they wear hearing aids only when R1 has visitors. In LPA’s interview with S1 on 12/29/21, S1 says that there was a problem with R1 losing their hearing aids and that family brought string to keep the hearing aids together but R1 took them off. S1 says that in December 2021, family directed S1 to keep them in the medication room because R1 always takes them off. S1 expresses that staff put R1’s hearing aids in when R1 has a visitor. During LPA’s interview on 10/24/22 with W1, W1 says that R1 would take out the hearing aids and lose them. W1 describes staff as putting them in when people came to visit, such as physical therapists, family, etc. W1 says R1 had a necklace to attach the hearing aids and that seemed to help a bit. W1 says replacement hearing aids cost thousands of dollars and that staff never lost them. Based on the evidence obtained, the allegation “Staff are not assisting resident with using hearing aids,” is deemed Unsubstantiated at this time. Interviews show that the facility stored R1’s hearing aids so that R1 would not lose them and attached them when R1 had visitors. No deficiencies cited. Exit interview conducted and the report emailed to the administrator.the state’s words, verbatim · CDSS document, Oct 27, 2022 · control 29-AS-20211222092253

Allegation investigated: Staff handled resident in a rough manner Resident left in soiled clothing for extended period of time Residents do not receive appropriate assistance with their medication Staff are not properly feeding the residents while in care Administrator harassed resident in care Staff lock resident's wheelchair wheels Staff do not have appropriate training to care for residents Staff use common wash cloths to clean residents

On 9/27/22 at 11:25 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced complaint visit to the facility listed above. LPA was greeted by staff in-person and spoke by phone with Jessica Bailey, Administrator, and explained the reason for the visit. At 11:51 am, the administrator arrived at the facility. On the allegation “Staff handled resident in a rough manner,” the complainant was concerned that a staff member had been rough with residents, specifically “rushes to put the residents in and out of the bathroom.” To investigate the allegation, LPA interviewed the administrator and witnesses and reviewed records. On 9/17/22 between 2:59 pm and 5:01 pm, LPA interviewed two witnesses. Both witnesses say they have not observed staff being rough with residents. On 9/19/22, between 11:19 am and 2:27 pm, LPA spoke with three witnesses who say they have not witnessed staff being rough with residents. On 9/20/22 at 8:20 am, LPA spoke with a witness who says that the resident they visit “thinks of staff as their children, loves it there, and can’t imagine being anywhere else.” - Continued on 9099-C. Unsubstantiated On 9/22/22 at 11:49 am, LPA interviewed the administrator. Administrator says that Resident #1 (R1) had a “rough time with Staff #1 (S1) at the beginning.” She explains that S1 was “efficient, to the point, brief, no extra stuff” and that R1 had a hard time getting used to S1’s approach. Administrator states that they asked R1’s family if they would like S1 taken off care duty for R1, and the family said “no.” On 9/22/22 at 4:57 pm, LPA spoke with Witness #1 (W1). W1 stated that when R1 first moved in, the “shower was a little rougher than normal,” and explains that R1 came from “a spa treatment-type bath and that it took R1 time to get used to a more efficient shower.” W1 says that R1 is “extremely sensitive physically.” On 9/22/22 at 12:10 pm, LPA reviewed S1’s disciplinary action. Records indicate there are no instances of S1 being counseled for behavior toward residents. Based on the evidence obtained, the allegation “Staff handled resident in a rough manner,” is deemed Unsubstantiated at this time. Interviews and records indicate that S1 was not handling residents in a rough manner. On the allegation “Resident left in soiled clothing for extended period of time,” the complainant remarked that Resident #2 (R2) “needed toileting assistance but the caregiver was told by a med-tech to stop helping R2 and to help in the kitchen.” Complainant says they later found that R2 was drenched in urine and feces. LPA investigated by interviewing the administrator and witnesses and reviewing records. On 7/12/21 at 3:59 pm, LPA spoke with the Administrator who informs LPA that a family member of a resident complained to her about their mother “sitting in her bowel movement for hours.” Administrator says that “a med-tech spoke with the daughter in the past about how long it takes for resident to eat stating it takes her 45 to 120 minutes, then she goes to the bathroom every day at 12:00 pm and 1:30 pm or 2:00 pm, and sometimes she has a bowel movement at the dining table during a meal.” Administrator states that staff brought the resident back after lunch and she had a bowel movement. On 9/22/22 at 1:45 pm, LPA reviewed administrator notes on the resident situation. In the notes, administrator writes “Checked into resident sitting in feces, watched video surveillance, found that it took her an hour and forty-five minutes to complete lunch, she was toileted right before and right after lunch…I served lunch that day and lunch the following day and witnessed it myself.” - Continued on 9099-C. On 9/17/22 between 2:59 pm and 5:01 pm, LPA interviewed two witnesses. Witnesses say that they have not seen nor smelled any soiled clothing, that the residents they visit are “always clean,” and they never witnessed residents being left in soiled clothing for an extended period of time.” On 9/19/22, between 11:19 am and 2:27 pm, LPA spoke with three witnesses who say that the residents they visit are never left in soiled clothing and there are no malodors. Witness #2 (W2) specified “I appreciate the most how they are taking care of R2 and keep R2 clean.” On 9/20/22 at 8:20 am, LPA spoke with Witness #3 (W3) who says that “it’s the opposite of what the complaint is and she (resident) is always clean.” On 9/22/22 at 4:57 pm, LPA spoke with W1 who said that R1 has never been left in soiled clothing for an extended period of time. Based on the evidence obtained, the allegation “Resident left in soiled clothing for extended period of time,” is deemed Unsubstantiated at this time. Interviews and record review indicate residents’ toileting needs are being met in a timely manner. On the allegation “Residents do not receive appropriate assistance with their medication,” the complainant’s concern was that there is only one med-tech and the med-tech does not stay in the resident’s room to ensure they take their medication. Complainant says there have been pills found on the floor of residents’ rooms. LPA investigated by interviewing the administrator, staff, and witnesses, and making observations. LPA interviewed five witnesses on 9/17/22 and 9/19/22. All witnesses say they did not have any problems with the medications for the residents they visited. One witness says they did not observe any pills in the resident’s room. On 9/27/22 at 12:00 pm, LPA interviewed the administrator. Administrator says there are two med-techs and one caregiver who are trained on medication dispensing and provided training documentation to LPA. On 9/27/22 between 11:47 am and 12:20 pm, LPA interviewed two staff. Staff say that only the med-techs and one caregiver are trained on medication dispensing and that they are the only ones dispensing medications. They say they have never seen med-techs leave a resident without ensuring the resident has taken his/her medication. They say that, in the mornings, most residents are given their medications in the dining room with breakfast and that there are only a couple residents who get them earlier in their rooms. Staff say there is a process in place for staff dispensing medications to ensure residents get their meds. One staff said that residents can refuse medications and then that is documented and brought to the attention of the lead med-tech. The other staff says they have seen where a resident drops a medication on the ground, the med-tech picks it up, and replaces it with a new one. - Continued on 9099-C. On 9/27/22, LPA reviewed staffing records. Staffing records from 7/12/21 indicate there are two medication technicians on schedule. LPA reviewed their medication training and noted they are up-to-date on training. Based on the evidence obtained, the allegation, “Residents do not receive appropriate assistance with their medication,” is deemed Unsubstantiated at this time. There is no evidence that residents are not receiving their medications nor that there are pills left on the floor. On the allegation “Staff are not properly feeding the residents while in care,” the complainant’s concern was that residents are “overfed and Resident #2 has gained a lot of unhealthy weight.” To investigate, LPA interviewed witnesses and reviewed records. On 9/27/22, LPA reviewed R2’s physician report and weight logs for January through August of 2021. R2 gained fourteen pounds in this time period. LPA reviewed the weight logs for five additional residents from January through August 2021 and found that these residents’ weights fluctuated within ten pounds. On 9/19/22 at 2:27 pm, LPA spoke Witness #2 (W2). W2 says that R2 “likes the food, thinks it is good quality, good portions, and good desserts and R2 likes sweets.” W2 says they have “No concerns about R2 gaining any weight” and states that R2 went through a big bag of Werther’s candy that family provided. On 9/20/22 at 8:20 am, LPA interviewed Witness #3 (W3). W3 reports that the family member they visit is a diabetic, and staff cater to her dietary needs by giving her sugar-free syrup on her pancakes and not giving her large portions of food and minimal fruit. W3 says that she enjoys their cooks and the food they serve. Based on the evidence obtained, the allegation “Staff are not properly feeding the residents while in care,” is deemed Unsubstantiated at this time. Interviews and records reveal that residents are getting an adequate daily food intake, and diets are specialized when needed. On the allegation “Administrator harassed resident in care,” the complainant was concerned that R1 was unable to reach staff to assist with toileting needs and called 9-1-1, and the administrator “confronted the resident and began to harass R1 for calling 9-1-1.” To investigate the allegation, LPA interviewed the administrators and witness. Continued on 9099-C. On 9/22/22 at 1:27 pm, Administrator Jessica Bailey says she remembers the incident happened “within one month of R1 moving in” and does not remember going into R1’s room and talking with R1 about it. On 9/22/22 at 1:40 pm, LPA spoke with Rachelle Tellez, Assistant Administrator. Ms. Tellez says she does not recall when anyone may have talked to R1 after the incident. On 9/22/22 at 4:57 pm, LPA spoke with W1. W1 says they remember the event distinctly. W1 says R1 was having panic attacks over not getting a hold of anyone and that it was “good that R1 called 9-1-1, it gave R1 a sense of empowerment.” W1 says R1’s “mood the next day was great because R1 felt empowered.” W1 expresses that R1 “never had anyone come in and give R1 a hard time. No one harassed R1.” Based on the evidence obtained, the allegation, “Administrator harassed resident in care,” is deemed Unsubstantiated at this time. Interviews conclude that R1 was not harassed by the administrators or any other staff. On the allegation, “Staff lock resident's wheelchair wheels,” the complainant’s concern was that staff lock residents’ wheels and specifically the wheels of Resident #3 (R3). To investigate the allegation, LPA interviewed staff and witnesses and made observations. On 9/17/22 between 2:59 pm and 5:01 pm, LPA interviewed two witnesses. The first witness says, “I have never witnessed staff locking my aunt’s wheelchair.” The second witness visited R3 and expressed, “I never observed staff using the wheel lock for restraint.” On 9/19/22, between 11:19 am and 2:27 pm, LPA spoke with three witnesses who report that the residents they visited and observed in the facility and who use wheelchairs, observed that the wheelchair locks were only used for safety, not restraint. On 9/20/22 at 8:20 am, LPA interviewed W3 who says that the only time they’ve seen staff lock a resident’s wheels is “in the van during transport.” On 9/22/22 at 12:45 pm, LPA interviewed the administrator. Administrator says that “staff lock wheels of all residents for safety, i.e. at the dining table.” She says “some non-memory care residents are able to unlock their own wheels.” On 9/27/22 between 11:47 am and 12:20 pm, LPA interviewed two staff. Staff say they only lock a resident’s wheelchair when performing a transfer and have observed other staff locking residents’ wheelchairs only for safety purposes. - Continued on 9099-C. On 9/27/22 at 12:48 pm, LPA toured the dining and living rooms. LPA observed six residents in wheelchairs. Two residents were moving through the area in their wheelchairs, the other four were sitting in one place. At 1:05 pm, LPA observed a resident in the front lobby strolling in her wheelchair. Based on the evidence obtained, the allegation, “Staff lock resident’s wheelchair wheels” is deemed Unsubstantiated at this time. Interviews indicate that staff are locking resident’s wheelchairs for safety purposes only. On the allegation “Staff do not have appropriate training to care for residents,” the complainant was concerned that staff do not have experience and do not receive proper training before caring for the residents. To investigate, LPA interviewed the administrator, staff and witnesses and reviewed records. On 9/27/22 at 12:00 pm, LPA interviewed the Administrator. Administrator states that new caregivers go through a 10-day training at 12 hours per day before they can work independently. Two staff interviewed by LPA on 9/27/22 say they have completed the 10-day training. LPA requested a sampling of three caregivers and obtained their 10-day New Hire Training Logs. All three completed their New Hire Training. On 9/17/22 between 2:59 pm and 5:01 pm, LPA interviewed two witnesses. One witness explains that the resident they visited had very high standards and that they felt staff were “less trained and didn’t know how to make beds, clean rooms, and shower residents.” The other witness says they had no issues with staff being competent. On 9/19/22 between 11:19 am and 2:27 pm, LPA interviewed three witnesses. Witnesses say the staff “have good training,” that “staff are quite good,” and “they’re fine, good staff.” On 9/20/22 at 8:20 am, LPA interviewed W3. W3 says they watch staff check on the resident they visit, take their blood sugar, and other interactions and W3 has no concerns about staff being trained. Based on the evidence obtained, the allegation “Staff do not have appropriate training to care for residents,” is deemed Unsubstantiated at this time. Interviews and records review indicate that staff have required training to meet the basic needs of residents in care. Continued on 9099-C. On the allegation, “Staff use common wash cloths to clean residents,” the complainant was concerned that staff use common wash cloths to clean resident’s buttocks and cloths are stained and ripped. LPA investigated by interviewing the administrator, staff and witnesses and making observations. On 9/17/22 and 9/19/22, LPA interviewed five witnesses. All witnesses say that linen was adequate and clean and that they had no concerns about the linen. However, four of the witnesses mentioned that they had an issue with the residents getting another resident’s clothing or that their clothing was missing during the laundering process. LPA advised the administrator and S2 on greater measures to ensure clothing is delivered to residents properly. On 9/22/22 at 12:45 pm, Administrator says that staff “use Sani wipes to clean residents’ buttocks and sometimes use cloth towels.” On 9/27/22 at 11:30 am, S2 also states that staff use sanitary wipes and occasionally use cloth towels to wipe residents’ buttocks. On 9/27/22 at 11:30 am, LPA toured the laundry room. LPA observed five bath towels, ten face towels, and five sheets. LPA sampled the linens and did not find significant issues with the linen. There were a few towels that were a bit ragged on the edges with minor stains but appeared to be in good shape. LPA advised administrator on replacing these soon. Administrator says she replaces them “all the time” and will take a look again to see what needs replacing. On 9/27/22 between 11:47 am and 12:29 pm, LPA interviewed two staff. Staff say they inform S2 when linens need replacing. Based on the evidence obtained, the allegation, “Staff use common wash cloths to clean residents,” is deemed Unsubstantiated at this time. Interviews and observations indicate that residents in care are receiving healthful accommodations. Exit interview conducted and the report emailed to the administrator.the state’s words, verbatim · CDSS document, Sep 27, 2022 · control 29-AS-20210709142244

Type of visit: Case Management - Incident

On 7/20/22 at 11:55 am, Licensing Program Analyst (LPA) Darlene Chavez conducted a Case Management - Incident visit to issue final findings and citations related to the Case Management visit conducted on 05/11/2022. LPA met with Rachelle Tellez, Assistant Administrator, and Leah Figaro, Human Resources Manager, and explained the purpose of the visit. On 5/11/22, from 2:37pm to 4:00pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced case management visit to the facility. LPA met with Jessica Bailey, Administrator, and explained the reason for the visit. On 5/11/22, Administrator faxed an incident report (LIC 624) and Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to Community Care Licensing (CCL) stating that, on 5/10/22, Staff #1 (S1) witnessed Resident #1 (R1) being sexually abused by Staff #2 (S2) in R1’s room. LPA interviewed the Administrator and obtained documentation pertinent to the investigation. LPA determined further investigation was needed. On 05/11/22, this case was referred to the CCL Investigations Branch (IB) and assigned to Investigator Elisia Rippe. Investigator Rippe contacted the San Luis Obispo Police Department (SLO PD) from 05/16/2022 to 06/06/2022 regarding the status of the investigation and to schedule joint interviews with witnesses. On 06/07/2022, at 10:30am and 11:37am, Investigator Rippe and SLO PD Detective Chris Chitty conducted interviews with the Administrator; at 10:47am and 11:20am, with R1’s representative; at 10:56am with R1; and at 11:46am, with S1. In addition, Investigator Rippe also reviewed Long Term Care Ombudsman (LTCO) reports and facility file documents related to R1. Continued on 809-D. On 05/10/2022, at approximately 9:00am, S1 went into R1’s room and observed S2 hovering over R1 with R1’s shirt pulled up and kissing R1’s breast. R1 stated they told S2 they did not want S2 to touch R1. The facility personnel asked S2 to leave the resident’s room. S2 attempted to visit R1’s room again. Facility personnel then escorted S2 out of the facility and contacted SLO PD law enforcement. S2’s employment with the facility was terminated effective 05/10/2022. On 05/11/2022, the facility self-reported that R1 disclosed that they were inappropriately touched by S2. The outcome of the SLO PD investigation is currently pending. Based on the information obtained through the LTCO report and joint interviews conducted with SLO PD, Investigator Rippe determined there was sufficient evidence to support a substantiated finding. Therefore, the allegation “Sexual Abuse – Facility Staff #2 (S2) inappropriately touched facility Resident #1 (R1)” is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). Exit interview conducted, appeal rights provided, a copy of this report issued.the state’s words, verbatim · CDSS document, Jul 20, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jul 21, 2022

Additional Personal Rights of Residents in Privately Operated Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from neglect...and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interviews and police record review, the licensee did not comply with the above section because S2 inappropriately touched R1, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 20, 2022

Plan of correction: Licensee terminated Staff 2. Licensee agreed to submit a plan to ensure all staff have ongoing training in personal rights of residents. Licensee will send a written commitment to LPA by 7/21/22 stating that all staff will have ongoing training in personal rights of residents.

Type of visit: Case Management - Incident

On 5/11/22 at 2:37 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced case management visit to the facility above. LPA met with Jessica Bailey, Administrator, and explained the reason for the visit. On 5/11/22, Administrator faxed an incident report (LIC 624) and Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to CCL stating that, on 5/10/22, Staff #1 (S1) witnessed Resident #1 (R1) being sexually abused by Staff #2 (S2) in R1’s room. Today, LPA interviewed the administrator and obtained documentation. Further investigation is needed. Exit interview conducted and a copy of the report emailed to the administrator.the state’s words, verbatim · CDSS document, May 11, 2022

Type of visit: Required - 1 Year

On 5/11/22 at 4:00 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Administrator Jessica Bailey and explained the purpose of the visit. LPA toured the facility with the administrator and observed the following: 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 are wearing masks. The facility has soap and hand sanitizing dispensers and paper towels in common bathrooms. The fire extinguishers (2) are located upstairs and downstairs next to the elevator doors. The extinguishers are fully charged and were inspected on 5/06/21. The administrator will ensure the extinguishers are inspected, take photos, and send to LPA by 5/18/22. At 4:25 pm, LPA conducted the Infection Control mitigation module with the administrator. No deficiencies cited. Exit interview conducted and report emailed to the administrator.the state’s words, verbatim · CDSS document, May 11, 2022

Type of visit: Case Management - Deficiencies

On 12/29/21 at 11:00 am, Licensing Program Analysts (LPAs) Darlene Chavez and Jenny Olson conducted a 10-day complaint investigation. During the investigation at 12:55 pm, LPAs observed that Resident #1 (R1) and Resident #2 (R2) have bed rails extending the full length on both sides of their common queen-sized bed. All four bed rails were in the upright position, each side of the bed having a top half rail and a bottom half rail. Resident #2 was asleep or resting in the bed at the time LPAs visited. Staff #1 (S1) stated that neither R1 nor R2 are on hospice. S1 provided documentation from R1 and R2 physician showing they are approved for half bed rails. LPA Chavez questioned staff as to why R1 and R2 had full bed rails, and S1 and Administrator stated they did not know, but that R1 and R2 fall “frequently.” LPA Chavez communicated to S1 and Administrator that full bed rails are not permitted and instructed them to immediately remove the bottom half rails on both sides of the bed immediately which S1 and Administrator did. Photos were taken. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were emailed.the state’s words, verbatim · CDSS document, Dec 29, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Dec 29, 2021

87608(a)(5)(B): Postural Supports. 87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The requirement is not met as evidence by: Based upon observation and interview, the licensee did not obtain hospice orders for full bed rails on R1’s and R2’s bed, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 29, 2021

Plan of correction: The Administrator has agreed to do the following: 1. Remove the bottom half bed rails immediately. Obtain hospice orders for full bed rails, if needed in the future.

Allegation investigated: Staff member denies residents beverage of choice Facility isolates resident to their bedroom Staff are not trained properly or adequately with resident’s assistance with daily living

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Jessica Bailey and explained the purpose of the visit. During the investigation, LPA conducted interviews with staff on 12/16/2019 around 8:31 AM, 3:45 PM, 4:11 PM, on 08/05/2021 at 12:34 PM and 12:51 PM and on 08/06/2021 at 1:11 PM. LPA conducted interviews with witnesses on 08/05/2021 at 1:14 PM, 1:42 PM, 1:44 PM, 1:58 PM, and on 08/06/2021 at 10:25 AM. LPA reviewed documentation on 12/16/2019 around 3:30 PM, on 08/04/2021 at 1:30 PM, 4:45 PM, on 08/06/2021 around 10:00 AM and on 08/09/2021 at 11:45 AM. Continued 9099-C Unsubstantiated On the allegation: Staff member denies residents beverage of choice. LPA interviewed Staff 1 (S1), Staff 2 (S2), Staff 4 (S4), Staff 5 (S5) and staff 6 (S6) as well as interviewed witness 1 (W1), Witness 2 (W2), witness 3 (W3), Witness 4 (W4), Witness 5 (W5) and Witness 6 (W6) none of the interviews conducted revealed staff member denying residents choice of beverage. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Facility isolates resident to their bedroom. LPA interviewed S1, S2, S4, S5, S6, W1, W2, W3, W4, W5 and W6 none of the interviews revealed residents were being isolated. W1-W5 interviews revealed residents were free to do what they wanted, and staff encouraged activities and socialization with the residents. Based on lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Staff are not trained properly or adequately with resident’s assistance with daily living. LPA interviews with S1, S2, S4, S5, S6 revealed that staff are trained properly and adequately to handle the residents care and assistance with daily living. Interviews with W1-W6 revealed the staff seemed to be trained and staff know how to take care of the residents properly. LPA reviewed training records of staff on 08/09/2021 at 11:45 am which show staff were trained according to regulation requirements. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report emailed to the administrator.the state’s words, verbatim · CDSS document, Aug 9, 2021 · control 29-AS-20191211111130

The state marks this report as 6 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.