Capra House Care Home

Type of visit: Case Management - Incident

On 9/5/2023, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit to follow up on an incident that was reported to CCLD on 9/5/2023. LPA met with Caregiver Macrina Brooks and Administrator Oscar Madrigal followed after explained the purpose of the visit. CCLD received a report regarding the family member (FM) of a resident (R1) claiming abuse because of R1 had a small skin tear on his/her right hand. FM also gets angry when facility receives a stop order for medication stating that only FM can make decisions for R1's medications. LPA has obtained pertinent documents regarding the issue for review. Waiting for additional document to be available in the facility and then to be emailed to LPA. No deficiency cited during today's visit. This report was reviewed and copy has been provided.the state’s words, verbatim · CDSS document, Sep 5, 2023

Allegation investigated: - Resident was injured by staff while in care

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings in regards to the investigation on the allegation received. LPA met with the licensee Juliet Pacaldo and explained the purpose of today's visit. During the investigation LPA conducted multiple interviews and reviewed pertinent documents. Interviews completed resulted in identifying two incidents, which were logged and reported, where a resident could have been injured. LPA could not prove that the resident was injured by staff intentionally. Both incidents discuss the nature of injuries sustained as being accidental where staff were in place and trying to assist the resident. LPA could not prove or disprove this allegation took place. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. No citations issued. Report is reveiwed with Juliet. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 13, 2023 · control 14-AS-20230126160552

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual required 1 year inspection visit focused on COVID infection control. LPA met with co-administrator Oscar Madirgal during today's visit and explained the purpose of today's Upon entry LPA was COVID screened and had temperature taken. LPA did observe COVID some signs posted a the exterior of the facility but LPA suggested to add more. LPA toured facility's building and grounds with Oscar. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Resident and staff daily temperature log is not current but facility has a policy in place to take temperatures of resident's who exhibit cold/flu symptoms. LPA advised on continuing the daily temperature check log of residents. Staff are screened via temperature check and COVID symptoms upon entry to facility. PPE supply is observed as in place in the assistant executive director's office. Medications, toxins and sharps are stored appropriately and inaccessible to clients. LPA discovered in the linen closet Comet and cleaning spray unlocked. Fire extinguishers are observed through out the facility as fully charged. Inspection date noted on a fire extinguisher adjacent to kitchen as inspected on 01/26/2023. Water temperature is tested at 130F in a resident bedroom in common hallway adjacent to a resident's room. Non-skid floor or non-skid shower mats are in place in resident room. Liquid soap is available and paper towels are available. Resident room adjacent to common bathroom is observed and they are equipped with the required furniture and light fixtures. First-aid kit is complete. A Disaster and Mass Casualty Plan is posted. Staff are observed wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact is reviewed. Administrator certificate is current. All staff and residents are fully vaccinated and boosted. Continued on attached LIC809-C Page 2 - Required 1 Year Annual The following updated forms are requested to be submitted to CCLD by 02/07/2023: • LIC 308 Designation of Facility Responsibility • LIC 500 Personnel Report • LIC 610E Emergency Disaster Plan • Copy of updated administrator certificate Citations are issued on attached LIC809D. Report is reviewed with administrator Oscar Madrigal.the state’s words, verbatim · CDSS document, Jan 31, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Feb 1, 2023

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This regulation is in violation as evicenced by: LPA tested the water temperature in the common bathroom located in hallway adjacent to resident room at 130F.the state’s words, verbatim · CDSS document, Jan 31, 2023

Plan of correction: Facility shall ensure that the water temperature in the facility meets regulatory standards outlined in Title 22. A written plan is to be recieved by the due date. Additionally a daily temperature and logging of temperature shall be taken for 72 hours. The log shall be received by the department certifying testing and monitoring for this period of time.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Feb 1, 2023

Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This regulation is in violation as evicenced by: LPA observed cleaning supplies such as Comet and cleaning spray stored unlocked in the linen closet adjacent to a residents room in a common hallway.the state’s words, verbatim · CDSS document, Jan 31, 2023

Plan of correction: Facility shall ensure that all cleaning solutions are to be locked an inccessible to clients at all times. During today's inspection staff removed the items and stored in locked area for cleaning solutions. **POC CLEARED ON THIS DAY**

Allegation investigated: - Facility failed to maintain working smoke alarms - Facility failed to report small fire to CCL as required

LPA Jeung met with and interviewed staff--including assistant administrator--and tested 6 smoke detectors; all are operable. LPA was told that battery in smoke detector in bedroom #3 was replaced last week. LPA also learned that on January 27 or January 28, a towel that was left in the oven resulted in smoke filling kitchen and moving into adjacent dining room. The smoke detectors are located on the other side of the house where the bedrooms are, and it's conceivable that they were not activated because smoke was confined to the side of the house where the kitchen and dining room are. Staff who were present on 1/27 or 1/28 said that the sliding door and windows were opened to clear the smoke out. It was evident during LPA's visit that management had not been informed about the smoke incident, so it was not reported to CCLD as an unusual incident. Management will review reporting requirements with staff. Based on this information, Ii cannot be proven that these allegations are true. Therefore, allegations are determined to be unsubstantiated, meaning that allegations could have occurred or be true, but there is not sufficient evidence to substantiate. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 4, 2022 · control 14-AS-20220128120323

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

During complaint investigation visit, LPA Jeung observed a deficiency of the CA Code of Regulations, Title 22, related to COVID infection control. Deficiency is cited on a following page. The following information/forms are requested to be submitted to CCLD BY 2/9/22: - Personnel Report (LIC500) - Designation of Administrative REsponsibility (LIC308) - Signed current lease agreementthe state’s words, verbatim · CDSS document, Feb 4, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 9, 2022

PERSONAL RIGHTS OF RESIDENTS Residents in all RCFEs shall have the following personal right: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met, as evidenced by absence of any COVID screening of LPA upon arrival to facility. Licensee failed to ensure that residents were ensured of COVID safety, as staff did not screen LPA nor ask for her to sign a visitor log, which poses a potential health, safety or personal rights risk to clients in care. Visitor log shall at leaset include responses to COVID screeniing questions, temperature, COVID vaccination verification, & contact number.the state’s words, verbatim · CDSS document, Feb 4, 2022

Plan of correction: Proof of correction to be submitted to CCLD BY DUE DATE, to include copy of revised visitor sign in log.