Heirloom Rose Garden

Type of visit: POC

On May 12, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced follow up plan of correction visit. LPA met with Administrator, Edmund Sunpayco, and explained the purpose of the visit. On 5/5/23, LPA Charitra and LPA Donato conducted an plan of correction visit to confirm facility's compliance with the citations that were issued on 4/21/23. Civil penalties for the following deficiencies; CCR 87468.2(a)(20), CCR 87211(a)(1), and CCR 87309(a) were assessed due to Licensee failing to provide CCL a plan of correction by due date. A total civil penalty of $2,100.00 was assessed for all 3 deficiencies ($700 for each deficiency). On 5/5/23, the Licensee submitted plan of corrections for deficiencies; CCR 87211(a)(1), and CCR 87309(a). Deficiencies are now verified as corrected and cleared. Civil penalties are stopped on 5/5/23. On 5/8/23, the Licensee submitted plan of corrections for deficiency; CCR 87468.2(a)(20). Civil penalty will be assessed from 5/6/23 through 5/8/23 for violation: 87468.2(a)(20) Additional Personal Rights of Residents in Privately Operated Facilities Personal Rights of Residents in All Facilities.A total of $300.00 is assessed today. Civil penalties are stopped on 5/8/23. Report is reviewed with Administrator and a copy is provided with appeal rights. A copy of civil penalty is provided.the state’s words, verbatim · CDSS document, May 12, 2023

Type of visit: POC

On May 5, 2023, Licensing Program Analysts (LPAs) Komal Charitra and Grace Donato conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citations that were issued on 4/21/23. LPAs met with Caregivers, I. Wanawan and A. Sunpayco and explained the purpose of the visit On 4/21/23, LPA Charitra and LPA Donato concluded a complaint investigation; complaint control #14-AS-20230106153247, which alleged that the licensee did not allow Resident #1 (R1) to return to the facility. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “87468.2(a)(20)” Additional Personal Rights of Residents in Privately Operated Facilities for not allowing R1 to return back to the facility because the facility was experiencing staffing challenges. The plan of correction was due by 4/28/2023. On 4/21/23, LPA Charitra and LPA Donato conducted a case management visit and cited the facility for CCR 87211(a)(1) Reporting Requirements for facility failing to report an incident that occurred on 12/9/22. The plan of correction for this citation was due by 4/28/2023. On 4/21/23, LPA Charitra and LPA Donato conducted an annual visit and cited the facility for CCR 87309(a) Storage Space, 87705(f)(1) Care of Persons with Dementia, 87705(j) Care of Persons with Dementia. The plan of correction for these citation were due by 4/28/2023. During the visit today, LPAs toured the facility and observed knives and chemicals to be locked and inaccessible to residents. LPAs also observed the door alarms to be in good repair and working condition. During the visit administrator/co-administrator was not present, and caregivers were unable to provide LPAs with a POC for the following cited deficiencies; CCR 87468.2(a)(20), CCR 87211(a)(1), and CCR 87309(a). Continue to 809C Due to the above 3 deficiencies not being corrected, and documentation not being submitted to CCLD by 4/28/2023, a civil penalty is being assessed in the amount of $100 a day for EACH DEFICIENCY from 4/29/2023 through 5/5/2023 and will continue to accrue until corrected. A total civil penalty of $2,100.00 is being assessed for all 3 deficiencies ($700 for each deficiency). Report is reviewed with Caregivers, however Caregivers refused to sign. A copy is provided of reports and civil penalties with a copy of appeal rights.the state’s words, verbatim · CDSS document, May 5, 2023

Allegation investigated: Licensee will not allow resident to return to the facility

On April 26, 2023, Licensing Program Analyst (LPA) Komal Charitra made an unannounced visit to deliver an amended report that was provided on April 21, 2023 by LPA Komal Charitra and LPA Grace Donato. LPA met with Caregivers, Mikhail Serrano and explained the purpose of the visit. On April 21, 2023, Licensing Program Analysts (LPAs) Komal Charitra and Grace Donato conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Caregivers, Mikhail Serrano and Angelo Sunpayco and explained the purpose of the visit. Administrator, Edmund Sunpayco and Co-Administrator, Rose Lo joined shortly thereafter. Regarding allegation that Licensee will not allow resident to return to the facility, according to the reporting party, the Co-Administrator was not allowing Resident 1 (R1) to return back to the facility due to R1’s behavior, lack of staffing, and R1’s difficult family dynamic. During the investigation, LPA interviewed Administrator, Co-Administrator, and staff members, reviewed R1’s file and reviewed the hospital discharge documentation. Based on hospital discharge notes reviewed, R1 was admitted to the hospital on December 9, 2022 due to shortness of breath. On December 28, 2022, R1 was to be discharged back to the facility, however R1 tested for COVID at the hospital. R1 isolated at the hospital till 1/6/2023 and was going to be discharged from the hospital on 1/7/2023, however on 1/6/2023, when the hospital contacted the facility, the Co-administrator indicated that she cannot accept R1 back on 1/6/2023 and 1/7/2023 due to lack of caregivers and having other COVID positive residents at the facility. Continue to 9099C Substantiated According to the Administrator, R1 was to be discharged from the hospital on 1/6/23, but the Co-administrator wanted R1 to remain at the hospital because there were 2 clients that were COVID positive at the facility. In addition, the Co-administrator acknowledged, she wanted to have R1 remain at the hospital because the facility was experiencing staffing challenges and was unable to provide for R1 and the other residents at the home until 1/7/2023. Nevertheless, although R1 returned back to the facility on 1/9/2023, the facility did not want to accept R1 back due to staffing challenges. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with Co-Administrator and a copy is provided with appeals rights.the state’s words, verbatim · CDSS document, Apr 21, 2023 · control 14-AS-20230106153247

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Apr 28, 2023

87468.2 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 in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents.... Violation of this regulation is evidenced by: Based on interviews conducted and information collected, the Co-administrator acknowledged, she wanted to have R1 remain at the hospital because the facility was experiencing staffing challenges and was unable to provide for R1 and the other residents at the home until 1/7/2023.the state’s words, verbatim · CDSS document, Apr 21, 2023

Plan of correction: Licensee/Administrator to review CCR 87468.2(a)(20) and submit acknowledgement of regulation. Administrator/Licensee to submit a written plan of to ensure incident does not happen in the future.

Type of visit: Required - 1 Year

On April 21, 2023, Licensing Program Analysts (LPA) Komal Charitra and Grace Donato conducted an unannounced annual inspection. LPA met with Caregivers, Mikhail Serrano and Angelo Sunpayco and explained the purpose of the visit. Administrator, Edmund Sunpayco and Co-Administrator, Rose Lo joined shortly thereafter. Upon arrival, LPA observed COVID signage posted on front door and temperatures were taken. LPAs toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 4 resident rooms and 2 full bathrooms. LPA toured the resident rooms and observed them to be private rooms with all required furntiure. LPAs observed resident room #3 to have an exit door with an alarm, however the alarm was observed to not be working. In addition, alarm was not working in the office room. Bathrooms were observed to be in good repair and equipped with non-skid mats. LPAs observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 68 degrees F is maintained and lighting is sufficient for comfort. Hot water temperature was measured at 110 degrees F throughout the facility. Staff training records were reviewed; food supplies were observed to be adequate. LPAs toured the kitchen, and observed sharps to be unlocked and accessible to residents. LPAs toured the garage and observed extra food, linen and resident supplies present. Washer and dryer was observed to be in good repair. LPAs observed toxins and chemicals to be unlocked and accessible to residents. According to staff, residents do not have access to the garage. LPAs advised caregivers to still keep chemicals locked. Facility is equipped with smoke detectors and a carbon monoxide detector. Fire extinguisher was last serviced November 3, 2022. Fire drill was last conducted in November of 2022 (Cont to 809C) All staff present at the facility was observed to have fingerprint clearance. Medications were observed to be locked and inaccessible to residents. LPAs reviewed residents and staff records. Resident records contain admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal, Needs and Service Plan, etc. Staff files contain personnel records, health screening, COVID-19 vaccination card, Job Description, Abuse Statement, First Aid, training records. Criminal Record Statement, etc. During the visit, 3 residents were observed in their rooms sleeping and one resident was observed in the dining room. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Co-Administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Apr 21, 2023

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On April 21, 2023, Licensing Program Analysts (LPAs) Komal Charitra and Grace Donato conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Caregivers, Mikhail Serrano and Angelo Sunpayco and explained the purpose of the visit. Administrator, Edmund Sunpayco and Co-Administrator, Rose Lo joined shortly thereafter. During the investigation of complaint control #14-AS-20230106153247, it was indicated that Resident #1 (R1) went to the hospital on December 9, 2022 due to shortness of breathe. On 4/21/23 during the complaint investigation, LPAs asked Co-Administrator if the facility submitted a copy of the Incident Report to CCL. According to the Co-Administrator, she indicated she did not submit a report to CCL. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Co-Administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Apr 21, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 28, 2023

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... Violation of this regulation is evidenced by: Based on interviews conducted, the Co-Adminstrator indicated that an incident report was not submitted to CCL when Resident 1 (R1) was admitted to the hospital on December 9, 2022.the state’s words, verbatim · CDSS document, Apr 21, 2023

Plan of correction: Licensee/Administrator to submit acknowledgement of CCR 87211.