Comforts of Home Senior Care

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst's (LPA's) De Leon and Kontilis conducted a CM-Annual Continuation visit to the facility above. LPA's met with Gary Gleissner, Licensee and Trina Dellinger-Gleissner Administrator/Licensee and explained the purpose of the visit. LPA's checked on the prior Deficiencies and Technical Violations to make sure they were completed. Several Technical Violations were not completed on the continuation visit. LPA's asked to review Resident records, Staff records, Staff training. Administrator was not able to provide LPA's records or training to review on visit. Administrator stated she would work on getting records to LPA's for review but could not provide them at the time of the visit. LPA De Leon completed a medication review on resident. LPA Kontilis interviewed 3 residents and 2 staff on duty. Exit interview conducted, deficiencies cited, technical violations issued, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Mar 17, 2023

The state marks this report as 108 pages; the online copy we transcribed has 21. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Rachael DeLeon and Kristin Kontilis conducted a Case Management visit to address deficiencies noted during a required Annual Inspection visit conducted on 3/7/2023. LPAs met with Gary Gleissner, Licensee and explained the purpose of the visit. At the time of the visit, LPAs reviewed residents’ records and conducted interviews with staff and residents. Interviews conducted revealed that Resident 1 (R1) sustained a fall in October 2022; facility administrator called 9-1-1 and R1 was transferred to the hospital. Interviews further conducted revealed R1 remained in the hospital and was eventually transferred to a skilled nursing facility then returned to the facility after several weeks. R1 was placed on hospice on or about 12/9/2022. R1 passed away at the facility on or about 1/29/2023. Upon record review and interviews conducted, LPAs determined no hospice notifications have been received by CCL although facility has a hospice waiver for two (2) residents. Records reviewed and interviews conducted revealed no Serious Illness/Serious Injury (LIC624) reports have been received by CCL since 3/5/2021. Records reviewed revealed no death reports (LIC624A) has been received by CCL reporting R1’s death and/or other residents’ deaths since 3/5/2021. LPAs counseled Staff 1 (S1)/Facility Designee on the importance of following the requirements in California Code of Regulations (CCR) 87632 Hospice Care Waiver and 87211 Reporting Requirements in their entirety to ensure adherence to the regulations. Pursuant to Title 22, Division 6, Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC809-D). Exit interview conducted. Deficiencies cited. Copy of report and Appeal Rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Mar 7, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(d)(2) · Plan of correction due date: Mar 14, 2023

87632(d)(2) Hospice Care Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above as CCL has not received hospice notifications for residents placed on hospice which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 7, 2023

Plan of correction: Licensee agrees to conduct training with all staff responsible for submitting hospice notification. Training records will show full names of attendees, date of training, and person conducting training with first and last names in print and signature.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a) · Plan of correction due date: Mar 14, 2023

87211(A)(1) Reporting Requirements. 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… This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above as CCL has not received Serious Illness/Serious Injury Reports and/or Death Reports since 3/5/2021 which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 7, 2023

Plan of correction: Licensee agrees to conduct training with all staff responsible for submitting Serious Illness/Serious Injury and/or Death Reports to CCLD. Training records will show full names of attendees, date of training, and person conducting training in print and signature.

Type of visit: Required - 1 Year

Licensing Program Analyst's (LPA's) De Leon and Kontilis conducted a 1 year Annual visit to the facility above. LPA's met with Gary Gleissner, Licensee and explained the purpose of the visit. LPA's took a physical plant tour of the facility with Licensee. The Facility has submitted a mitigation plan and Emergency Disaster Plan to the department. The facility has not submitted an infection control plan to the department. The facility has a central entry point to sign in and symptom screen. Routine symptom screening is being conducted on all client in care and anyone showing any signs or symptoms is isolated and tested. Signs are posted at entrance and in the common areas of the facility regarding Covid-19. Hand Sanitizer is available at entry, every room, and the facility has 5 resident bedrooms and 2 resident rest-rooms with plenty of soap, paper towels, toilet paper, and hand washing signs. Trash bins have covers. Facility has 30+ days of PPE supplies. Facility staff wear masks at the facility and when on outings with clients. Facility staff will wear full PPE with N95 masks with face shields when dealing with any pending or confirmed cases of Covid-19. Facility will keep track of staff vaccinations. Facility staff have non-punitive sick leave policies and sick staff are requested to stay home and not report to work if they are ill. Facility has developed policies for Covid-19 precautions. PPE supplies are stored in storage areas accessible to staff working. Facility audits all supplies and replenishes when low. Administrator has a plan in place for back-up staffing when and if needed. All residents in care have the right to reject medical services. The facility keeps staff on duty who is trained and competent to handle and deal with emergency personnel. Continued 809-C The facility has an emergency plan which was not posted. Residents records were reviewed and all 5 residents in care are missing required forms. 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. Smoke and carbon monoxide detectors are present in the facility they are dual and hard wired. The facility did not have self closing and self latching gates as required by regulation. The kitchen oven, stove, and grease around the area needs to be cleaned. The showers do not have non slip mats. Cleaning products were not locked and some were left in areas accessible to residents. LPA Kontilis tested water in resident rest-rooms temperature was 117.5 F. Fire extinguishers were charged but had not been inspected since 11/20/2019 or none of them had a receipt attached for proof of purchase within 1 year. LPA's will return at a later date to complete the annual inspection to review remaining resident files, staff files, training records and to conduct interviews as well as follow up on technical violations issued on today's visit. Exit interview completed, technical violations issued and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Mar 7, 2023

The state marks this report as 108 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 10:55 AM. Administrator Trina Dellinger arrived at 11:10 am. A Mitigation Plan has been submitted to CCLD. LPA was greeted by Staff 1 (S1). LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. There is one resident currently on hospice. Entrance interview conducted: At the time of the arrival, there were two (2) staff on duty and six (6) residents in care. LPA met with Administrator Trina Dellinger throughout the inspection. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. Entrance interview conducted. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the facility for fire safety, personal accommodations, and food service. First aid kits were observed to be complete. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There are five (5) fire extinguishers with current fire inspections. There are a total of 9 smoke/carbon monoxide alarms throughout the facility. Snacks and beverages are available for Residents in the facility upon request. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Cleaning agents and the kitchen trash can are kept in a locked cabinet under the kitchen sink. Medications are kept in a locked centrally stored cabinet. Sharps are kept in a locked drawer in the kitchen. The backyard has a covered patio with outdoor furniture, and a locked shed. The front and backyard have seating areas, potted plants, and paved walkways conducive for outdoor visitations. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. There is one private bedroom for staff behind the kitchen and laundry The living room and dining area are neat and clean. The facility maintains a comfortable room temperature measured at 12:05 pm. Hallways, bedroom doors and walls are in good repair. The facility has five (5) bedrooms for a capacity of six residents. Bedroom #5 is a shared bedroom with two residents. All of the bedrooms are furnished with lights and nightstand lamps to provide sufficient lighting. There are two bathrooms in the facility available for use for all residents. All persons associated with the facility have a criminal background clearance. Exit interview conducted. No citations were issued. A copy of the report has been issued.the state’s words, verbatim · CDSS document, May 18, 2022