The Wright Place

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Jo Ann Wright, Administrator (ADM). During visit, LPA Marrufo observed that ADM was preparing food in aluminum trays in the kitchen. ADM stated that ADM has a job today delivering catered food to a board meeting. ADM stated she is getting paid for the catered food. LPA Marrufo observed food trays, a baked cake that ADM stated she baked in the facility kitchen, a pot of gravy, and a propane-powered stove in the outside of the facility with a pot of heated oil. LPA Marrufo observed a tray of fish covered in flower that ADM stated she will cook in the outdoor stove. LPA Marrufo reviewed the resident records. LPA Marrufo observed that there were 2 medications without prescription labels and two bottles of medications that had the incorrect amount of pills based on the start date. LPA Marrufo observed resident R1's Appraisal/Needs and Services Plan was missing 2 out of 4 pages and was not signed by client or client's representative. R1's Safeguard for Property/Valuables is not the official LIC form and does not have client's signature/initials. LPA Marrufo toured the kitchen area and found 4 cans of expired food. LPA Marrufo observed 2 out of 2 bathrooms and observed the water temperature to be 125 F. LPA Marrufo tested the facility carbon monoxide detectors and smoke alarms. 2 out of 2 carbon monoxide detectors functioned properly when tested. 4 out of 7 smoke detectors functioned when tested but had a very faint alarm sound when tested. ADM stated during visit to have conducted an emergency disaster drill, but does not keep an emergency disaster drill log. See LIC809-C for more information. Page 1 of 2. LPA Marrufo observed 2 out of 2 bathrooms. Each bathroom had available soap, paper towels, and showers with chairs, hand railings, and mats. The water temperature measured at 115 F in 2 out of 2 bathrooms. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. A civil penalty of $250 was issued for a repeated violation. An Advisory Note was issued. See LIC9102 for more information. This report was reviewed with ADM Jo Ann Wright and a copy of the report and appeal rights were provided. Page 2 of 2. END REPORT.the state’s words, verbatim · CDSS document, Sep 21, 2023

Allegation investigated: Staff administered supplements to residents without prescription Licensee is operating an alternate business in the facility

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation and met with Jo Ann Wright, Administrator. On 08/14/2020, the Department received a complaint with the above allegations. LPA Marrufo conducted an initial complaint visit on 08/24/2020. During interview on 08/24/2020, ADM stated to have administered 5HTP pills to resident R1. During review of records, LPA Marrufo did not find 5HTP as a prescribed medication for R1. Two witnesses stated that the medication was not prescribed to R1. See LIC9099-C for more information. Page 1 of 2. Substantiated LPA Marrufo obtained a document from the East Palo Alto Sanitary District board meeting held on 10/15/2018. The document states the East Palo Alto Sanitary Board paid $560 to “Joann Wright Catering” for “Catering Services for 10/14/18 RBM and 10/10/18 SBM.” The address for “Joann Wright Catering” is stated in the document as 2525 Annapolis St. East Palo Alto, CA 94303. During interview on 08/24/2023, ADM stated that “RBM” stands for “Regular Board Meeting” and “SBM” stands for Special Board Meeting.” ADM stated to have provided catering services for the East Palo Alto Sanitary District and to have prepared the home in the facility kitchen. ADM stated to have been paid for catering services for businesses throughout East Palo Alto. Based on records review and interviews with residents and staff, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. This report was reviewed with ADM Wright and a copy of the report and appeal rights were provided. R1’s Physician’s Report states R1 requires a special Consistent or Controlled Carbohydrate (CCHO) diet. ADM provided LPA Marrufo with R2’s Physician’s Report, which only included the first 2 out of 6 pages and was missing the page that indicates if R2 requires a special diet. R2’s Discharge Medication form from a skilled nursing facility on 09/08/2019 indicated R2 was ordered a CCHO diet. LPA Marrufo obtained a copy of a letter from R1’s family stating what food they requested be served to R1. During interview on 08/24/2023, ADM stated to have followed the food recommendations provided by the family in the letter. ADM also stated to have provided soft foods for R2. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 This report was reviewed with ADM Wright and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 26-AS-20200814091452

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205(a) · Plan of correction due date: Aug 25, 2023

87205 Accountability of Licensing Governing Body(a): The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement was not met as evidenced by: Licensee/Administrator has operated a catering service business at the facility, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2023

Plan of correction: Licensee agrees to submit plan of correction by POC date to CCL stating how licensee plans on preventing her catering business and any other business or activity which is not related to the licensing of the facility to be conducted at the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Aug 25, 2023

87465(e) Incidental Medical and Dental Care For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement was not met as evidenced by: ADM Wright provided R1 with a supplement not prescribed by R1's physician, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2023

Plan of correction: Licensee agrees to submit a plan to CCL by POC date to review CCL regulation 87465(e) and ensure all staff, including licensee/administrator, understand they are not to administer medications to residents that are not prescribed by the resident’s physician.

Allegation investigated: Facility staff is injecting resident with insulin

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Jo Ann Wright, Administrator (ADM). On 08/25/2020, the Department received a complaint with the above allegations. On 08/26/2020, LPA Marrufo conducted an initial complaint investigation visit. During interview on 08/26/2020, ADM stated to have injected resident R1 with prescription medication for diabetes. During interview on 08/24/2023, R1 stated that ADM has in the past injected R1 with diabetes medication into R1’s arm and without R1’s assistance. Based on records review and interviews with staff and residents, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated. See 9099-D forthe state’s words, verbatim · CDSS document, Aug 24, 2023 · control 26-AS-20200825133742

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(a) · Plan of correction due date: Aug 25, 2023

87629 Injections (a): The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This requirement was not met as evidenced by: Administrator stated to have administered R1 with injection medication, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2023

Plan of correction: Licensee agrees to submit a plan to train all staff to not inject resident with any medication and to understand that only residents or appropriately skilled professionals may administer injections.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Jo Ann Wright. During visit, LPA Marrufo toured the facility. LPA Marrufo observed there to be a visitor screening form and thermometer available to screen visitors. LPA Marrufo observed there to be a PPE supply of at least 30 days. LPA Marrufo observed there to be a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed there to be available cleaning supplies. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Jo Ann Wright and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Fae Green. During visit, LPA Marrufo toured the facility hallways and observed the facility hallways to be clear of obstructions. The rolling clothing hanger was no longer observed to be in the hallway. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Fae Green and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Jo Ann Wright. During visit, LPA Marrufo toured the facility. The facility entrance did not have any materials to screen and log symptoms and temperatures for visitors. LPA Marrufo toured the bedrooms, bathroom, and dinning area. LPA Marrufo observed the facility PPE supply. LPA Marrufo observed that Administrator Jo Ann Wright's clothes were in a rack in the common hallway. Administrator Jo Ann Wright stated that resident records have not been organized into separate and complete records. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information. Advisory Notes were issued. See LIC9102s for more information. LPA Marrufo requested updated copies of the following documents: LIC308 Designation of Administrative Responsibility LIC610 Emergency Disaster Plan LIC500 Personnel Report This report was reviewed with Administrator Jo Ann Wright and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 16, 2021