Santa Maria Terrace

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct an annual continuation visit at 9:45 a.m. LPA met with Administrator and informed them of the reason for the visit. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility has four stories, 123 assisted living units. LPA toured building's main lobby, 12 resident rooms, dining room, kitchen, TV room, library, activities room, 2 stairwells, and garden. KITCHEN: LPA toured the kitchen around 10:00am. Kitchen appliances were clean and in operable condition. The facility has a sufficient supply of perishable and non-perishable food as well as emergency food and water. Common areas: All furniture was observed to be in good condition. Carbon monoxide detectors were tested and operational at the time of the visit. LPA observed required postings throughout the common spaces. The fire extinguishers were charged and serviced on 9/9/2022. The fireplace in the TV room is screened and inaccessible. Outdoor areas had umbrellas and other covered outdoor area equipped with furniture for resident use. Washer and dryers were functioning and in operable condition. Restrooms: Resident rooms had private restrooms which were clean and sanitary and in operating condition with non-skid mats/strips. All resident and public bathrooms were sufficiently stocked with soap and paper towels. Continued on 809-C INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate. Exit interview conducted. A copy of the report was provided. The last disaster drill was conducted on 8/31/2023. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 7, 2023

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. LPA met with Administrator and informed them of the reason for the visit. Records: LPA reviewed resident and staff records. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete. LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete. MEDICATIONS: Medications review began around 1:30 p.m. The medications are centrally stored and locked in a med cart in a medication room. Medications are labeled and checked for expiration dates. LPA advised the Administrator to ensure that all the necessary information is properly documented on the CSMAR. LPA interviewed two (2) care staff members. LPA observed two (2) staff were not associated to the facility. Administrator thinks a staff accidentally disassociated them by mistake. During today’s visit, the LPA obtained copies of the following: staff roster, resident roster and current liability insurance. Due to time constraints LPA was unable to finish the annual and will return at another date to continue the annual inspection. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights was issued.the state’s words, verbatim · CDSS document, Sep 6, 2023

The state marks this report as 9 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide complete records to authorize representative.

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23 and 6/12/23 and and requested relevant documents, and Wellness Director on 5/30/23. LPA met with Administrator and explained the purpose of the visit. On the allegation: Staff did not provide complete records to authorize representative. It was alleged that R1’s responsible parties requested records multiple times with no response. Interviews revealed the responsible party wanted records of the time medication was given and a staff agreed to check with IT to see how to print that information and would get back to them. At the time of the visit the staff said it still wasn’t provided. Interviews also revealed that the MAR and other documents wouldn’t print when the responsible party requested it. Staff wasn’t sure if it had been given but agreed to check. Based on the information obtained, the responsible party still hadn’t received records requested as of mid April, therefore the allegation is deemed Substantiated at this time. Exit interview conducted, copy of report and appeal rights were printed. Substantiated LPA was provided pictures of the Excedrin Migraine bottle provided to the facility. There was one Kirkland “Migraine Headache Relief” Bottle (250mg Acetaminophen, 250mg Aspirin, 65mg Caffeine), 400 count with a lid that has “NOC” written and “noon” “evening” and “bedtime” stickers. There is another sticker that says “Directions: 2 tab po 4 times a day” on that bottle. There was also an Excedrin Migraine bottle with a “morning” sticker on the lid. The reporting party stated no Acetaminophen bottle was returned to R1 when they moved out of the facility. Reporting party stated they feel R1 was given the Kirkland Migraine Headache Relief instead of Acetaminophen. The Kirkland Migraine Headache Relief has Acetaminophen in it, and it was possibly given 4 times a day as the Acetaminophen, in addition to the 2 tabs of Excedrin Migraine. LPA visited the facility on 3/2/23 and observed there to be leftover medication for Resident 1 that was not picked up, including a Kirkland Acetaminophen Extra Strength 500 count bottle. LPA interviewed MedTech’s who said it was possible that the Kirkland Migraine Headache Relief was given instead of the Acetaminophen, because the bottles look almost identical and both have acetaminophen as the first ingregient. When LPA interviewed the MedTechs, LPA showed them pictures of the two bottles (Acetaminophen and Kirkland Migraine Headache Relief) and asked which medication they would give for Acetaminophen. Only one MedTech indicated they would give the Kirkland Migraine Headache Relief, then later stated they were only 50% sure, while the rest of the MedTechs stated they were not sure. Wellness Director stated that while it is very possible the bottles were mixed up because they both have Acetaminophen as the first ingredient, there is a 7 step process that Medtechs go through to ensure the right medication is being given. Wellness Director stated for example, the process is for the Medtech to pull out all bottles that had “morning” on them that would have included the Excedrin Migraine, Kirkland Migraine Headache Relief, and Kirkland Acetaminophen and go through each order for the morning to make sure the correct medication is dispensed. However, they could see the possibility of them dispensing the Migraine Headache Relief as Acetaminophen because they look so similar and appear to match. LPA interviewed the family who stated they can’t remember if they gave the facility a brand new bottle of any medications or if some were opened. LPA reviewed the Centrally Stored Medication and Destruction Record, which indicated the quantity were full bottles, but the Medtech’s interviewed stated they didn’t know they had to count the medications received if the bottles were open. This will be addressed in a Case Management visit. Continued on 9099-C Based on the information obtained, there is not enough evidence to prove an incorrect medication was given, therefore the allegation is deemed Unsubstantiated at this time. LPA recommends the facility provide additional medication training to MedTechs to ensure they fully read the bottle of medication, instead of relying on how the bottle looks or on stickers. Exit interview conducted, copy of the report was printed and emailed.the state’s words, verbatim · CDSS document, Jun 15, 2023 · control 29-AS-20230224144738

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Jun 22, 2023

87506(c)(1) The licensee shall be responsible for storing active and inactive records...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the facility did not make records available to the resident or representative, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Administrator agreed to submit a statement of understanding of regulation 87506 and will make a plan on how to follow up on record requests in a timely manner and submit to CCL by 6/22/23.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Olson conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20230224144738). The purpose of the visit is to issue a citation for deficiencies observed during the complaint investigation. During the complaint investigation, the following deficiency was observed: Facility Centrally Stored Medication and Destruction Record (CSMDR) records for Resident #1 (R1) were missing the quantity for Vitamin C, Hydrochlorothiazide. The other medication had the total amount listed on the bottle, not actual amount. CCL received an incident report on 3/9/23 stating Resident 2 (R2) noticed residents Alendronate needed a refill. This is a weekly dosed medication with the refill date to be 3/1/23 but all weekly doses were given. The first dose was given on 3/3/23 and 3 more doses given daily, leaving resident without weekly dose for the month of March. Citations issued, exit interview, copy of report, appeal rights were printed and emailed.the state’s words, verbatim · CDSS document, Jun 15, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 15, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not follow doctors orders and properly assist resident with medication, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Facility immediately took the medtech responsible off medication passes and retrained medtechs on the 7 steps of issuing mediation. Plan of correction complete.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Jun 22, 2023

87465(h)(6) Incidental Medical and Dental Care (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (C) The drug name, strength and quantity. This requirment was met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not assure the centrally stored medications had the correct quantity, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Administrator agreed to train medtech's on the proper way to fill out the centrally stored medication log and submit training to CCL with name, date, and topic covered by 6/22/23.

Allegation investigated: Facility did not issue a correct refund

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA requested relevant documents, interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23, and interviewed Wellness Director on 3/28/23. LPA met with Wellness Director and explained the purpose of the visit. On the allegation: Facility did not issue a correct refund. It was alleged that there were double charges for tray service and R1 was not issued a correct refund. LPA reviewed R1’s invoices from June 2022 through March 2023 and observed multiple charges, credits, and adjustments. LPA made a spreadsheet with all charges and credits and observed the following: On 7/1/22, $300 was charged for “Tray Charges.” On 7/1/22, there was a second charge of $438 for “Tray Charges” for the same month. No refund was issued for the duplicate charge. On 9/1/22 the facility billed $300 for tray charges as well as another charge for $528 for tray charges on the same day. The $528 charge was refunded on 11/1/22. On 10/1/22, $300 was charged for “Tray Charges”. Continued on 9099-C Substantiated On 10/26/23 there was a second tray charge of $546. No refund was issued for the duplicate charge. Administrator stated there is a flat fee for tray service. Administrator issued a refund to R1 for the double charges on 4/24/23 for $987, after the initial complaint visit. Based on the information obtained, the allegation, Facility did not issue a correct refund is Substantiated. A Technical Violation is issued because the facility issued a refund. Exit Interview Conducted, copy of report, and appeal rights was issued via email and printed. Interviews with care staff revealed that they would check on (R1) every 2 hours but stated R1 was mostly independent and rarely needed assistance with incontinence care. LPA asked Wellness Director why staff continued to check on R1 even after incontinence care was removed from the care plan. Wellness Director stated that all new residents get Wellness Checks and Escort Service added to their plan free of charge for the first week. Wellness Director stated that the Wellness Checks and Escort Service were not removed until 11/23/22. LPA reviewed R1’s Physician’s Report dated 5/9/22 which states resident has bowel and bladder impairment, and notes say “incontinence/Depends”. “Able to care for own toileting need” is not checked yes or no, but under notes states: “may need assist with transfer.” LPA reviewed facility invoices and observed R1 was charged full price ($450) for incontinence care for June and July 2022 but was later refunded and only charged a total of $285 for the dates between 6/6/22 and 6/23/22. LPA also observed R1 was charged $90 in June and $300 in July for shower assistance but later refunded and only charged a total of $10. Due to the needs listed on the physician’s report, the facility charged R1 for the assistance given between 6/6/22-6/23/22 while determining the resident’s real needs. The facility stopped charging for services not needed and refunded a proportional amount to R1. Based on the information obtained, the allegation, Facility charged resident for services not needed, is unsubstantiated at this time. Exit interview conducted, copy of report was printed and emailed.the state’s words, verbatim · CDSS document, May 30, 2023 · control 29-AS-20230224163929

Allegation investigated: Facility did not inform authorized representative of change in living arrangement.

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23 and requested relevant documents. LPA met with Administrator and explained the purpose of the visit. On the allegation: Facility did not inform authorized representative of change in living arrangement. It was alleged that Resident 1 (R1) has dementia yet the facility allowed Resident 2 (R2) to move into R1’s apartment and didn’t inform the authorized representative. All staff interviewed stated that R2 frequently sleeps over and stays in R1’s room all day and night. Some staff state they’ve seen R1 in R2’s room on occasion, usually for coffee in the morning. Administrator stated they did not allow the move, they had no idea until the responsible party called on 2/27/23 and told them R2 moved into R1’s apartment. Staff went to check and saw R2’s closet empty. Continued on 9099-C Unsubstantiated Staff notified R2 that they did not have permission to move in and needed to be out the next day. The next day, 2/28/23 R2 moved out. Administrator checked the facility cameras and saw R2 and R1 carrying a cart of things to R1’s room on 2/27/23 at 4:23 pm and then taking a cart back on 2/28/23 at 9:20 am. LPA interviewed multiple care staff and housekeepers who stated that they had no idea R2 moved in with R1. R2 moved their belongings into R1’s room without notifying staff and when no staff were around in the hallway. As soon as Administrator and staff were aware of the room movement, they acted quickly to move R2 back into their own room. Based on interviews, the allegation: Facility did not inform authorized representative of change in living arrangement is Unsubstantiated. Exit interview conducted, copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 26, 2023 · control 29-AS-20230228161535

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Olson conducted an unannounced Case Management- Deficiencies visit to ensure the quality of care provided based on facility had a COVID-19 outbreak and was told multiple times to report cases timely and submit incident reports. During today’s visit, LPA Olson met with Joanna Enriquez, Administrator and explained the reason for the visit. On 12/27/22 Administrator informed LPA Olson that multiple residents and a staff have tested positive for COVID. LPA Olson asked by email for the required information on 12/28/22 and again by email on 12/30/22. Administrator didn’t send required information to LPA until 01/02/23. On 01/03/23 LPA Olson emailed Administrator and Wellness Director that Incident Reports were due that day to be considered on time per regulation (87211). The facility didn’t send the resident incident reports until 01/09/23 (6 days late) and Staff Incident reports were received on 01/16/23 (13 days late). On 01/09/23 LPA Olson sent an email to Wellness Director and Administrator stating again they didn’t follow reporting requirements after receiving another incident report stating a new resident tested positive for COVID on 01/04/23. On 1/18/22 CCL received another incident report stating a new resident tested positive for COVID on 1/10/22 which is both a late incident report (1 day late) and late COVID reporting (7 days late). Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): A $250 Civil Penalty for a repeat violation was issued. Exit interview conducted, copy of report, civil penalty and appeal rights were emailed to Administrator.the state’s words, verbatim · CDSS document, Jan 19, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 26, 2023

87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish... the following: (1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below.... This requirment was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not submit a written report within 7 days, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 19, 2023

Plan of correction: Administrator agreed to submit a plan to ensure written reports will be submitted to CCL within 7 days and submit plan to LPA by 1/26/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(2) · Plan of correction due date: Jan 26, 2023

87211(a)(2) Reporting Requirements (a) Each licensee shall furnish....reports ...(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents...within 24 hours either by telephone or fax... This requirment was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not report an epidemic outbreak within 24 hours, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 19, 2023

Plan of correction: Administrator agreed to submit a plan to ensure occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents will be reported to CCL within 24 hours and submit plan to LPA by 1/26/23

Allegation investigated: Facility staff are making medical decisions for residents in care

Licensing Program Analyst (LPA) Olson conducted an unannounced follow up complaint visit to issue final findings. LPA requested documents and interviewed staff and residents on 8/31/2022 and Wellness Director on 09/14/2022. On the allegation: Facility staff are making medical decisions for residents in care. It was alleged that Resident 1 (R1) refused to go to the hospital on 08/25/2022 after a fall, but the facility made the decision that R1 needed to go to the hospital and had the paramedics transport R1 against R1’s wishes. Interview with Wellness Director revealed that R1 hit their head and had a bump on their forehead. Wellness Director stated the facility had a policy that when a resident hits their head they must go out via ambulance and see a doctor regardless of their wishes to be seen. Staff interviews revealed that R1 never wants to go to the hospital and has a general mistrust for doctors. Continued on 9099-C Substantiated Emergency Service Personnel interviews revealed that when a resident refuses they usually perform a cognition test and if the patient is cognitive and refuses to go to the Hospital, they provide the resident with a release form for liability and it is against patient’s rights to force them to leave. Emergency Personnel stated the Wellness Director made emergency personnel take R1 to the hospital even though they didn’t feel R1 had to go and R1 refused. LPA informed Wellness Director that the facility cannot force the resident to go to the hospital. Wellness Director stated the staff are not trained and unable to monitor the resident for a change of condition and they cannot put that kind of pressure on the staff in case the resident has a brain bleed and passes out or passes away later. LPA informed Wellness Director that the facility should seek medical attention by calling 9-1-1 and have the resident assessed by Emergency Medical Personnel. Based on the assessment done by Emergency Medical Personnel and the resident and/or Power of Attorney’s (POA) decision, the resident may refuse to be transported. LPA explained usually the Emergency Medical Personnel will have the resident sign a waiver that explains refusing medical services. LPA explained residents have the right to refuse medical care, the same way they have the right to refuse other care. Based on interviews this allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D) Exit interview conducted. Report and Appeal Rights issued via email. There is insufficient evidence to substantiate this allegation, therefore the allegation is deemed unsubstantiated at this time. However, LPA recommends the facility ensure staff are aware of the powers a resident’s POA has to mitigate potential issues, and advises the Wellness Director to relate accurate information to Emergency Medical Personnel. On the allegation: Facility did not provide emergency information timely to emergency medical personnel. It was alleged that the facility takes a long time provide resident information to Emergency Personnel. Interviews revealed that after MedTech’s call 9-1-1, they must go to the med room, find the residents emergency binder, make a copy of the Emergency contact and Physicians report then look up their most recent Medication list and print it. Most staff stated this process is lengthy and they have suggested to management many times to make it more streamlined and timely. Interviews with Wellness Coordinator and Wellness Director stated they don’t have the med list preprinted because it changes often and after some practice the MedTech’s should be able to gather the documents in 5 minutes or less. One staff interview revealed that sometimes the binders are unorganized, in the wrong place and they are unable to provide Emergency Personnel with resident records. The staff was unable to provide specific details about when they were unable to provide medical records to emergency responders. LPA observed the resident record room was cluttered with papers and observed resident binders not in their designated spots. Based on observation and interviews, there was insufficient evidence to prove information was not provided timely to emergency medical personnel, therefore the allegation is deemed unsubstantiated at this time. However, LPA recommends the facility streamline their process for gathering emergency information for first responders, and recommends the record room be more organized. Exit interview conducted, copy of the report emailed to Administrator.the state’s words, verbatim · CDSS document, Oct 28, 2022 · control 29-AS-20220826113002

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Oct 28, 2022

87468.1(a)(16) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement was not met as evidcned by: Based on interviews, the licensee did not meet the section cited above as resident was not given the right to reject medical care, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2022

Plan of correction: The administrator understands their policy of transporting residents to the hospital even when the resident refused must be rescinded. The administrator agreed to rescind the policy immediately and will train all staff on resident’s rights and submit training to CCL by 11/04/2022

Allegation investigated: Facility did not meet resident's care needs Facility did not follow refund policy

Licensing Program Analyst (LPA) Olson conducted an unannounced follow up complaint visit to issue final findings. LPA requested documents and interviewed staff on 10/10/2022 and 10/28/2022. LPA interviewed Reporting Party on 10/17/2022. LPA met with Administator Joanna Enriquez. On the allegation: Facility did not meet resident's care needs. It was alleged that the facility did not shower Resident 1 (R1) twice a week or provide proper toileting assistance. Staff interviews revealed that R1 was difficult to bathe and would often refuse to shower. Staff stated that R1 did not have a shower chair at first and staff had to give R1 a sponge bath until the family provided one. R1 moved into the facility on 5/6/22, and LPA reviewed R1’s care notes from 5/6/22 through 7/15/22. Records indicate R1 did not have a shower after moving in 5/6/22 until 5/21/22, and the next shower after that was on 6/11/22. There were no documented refusals between 5/6/22 and 5/28/22. Records show that R1 did not receive two showers per week at the facility. Continued on 9099-C Substantiated LPA reviewed toileting assistance records from 5/6/22 through 6/30/22 which indicated missing entries on 6/1, 6/7, 6/9, 6/16, 6/18, and 6/23. Interviews revealed each shift (morning, afternoon and night) must check off each task once complete. The dates listed above were missing the NOC shift entry which indicated R1’s toileting needs were not met during that shift. Based on record review and interviews, this allegation is deemed Substantiated at this time. On the allegation: Facility did not follow refund policy. Reporting Party stated Resident 1 moved in on 5/6/22 and moved out on 7/19/22 and therefore is entitled to a 40% Community Fee Refund. LPA reviewed R1’s admission agreement page 6 which states: “4.1. Community Fee Refund Policy…4.1.4. If the resident leaves the Community for any reason during the third month of residency, the resident is entitled to a refund of 40 percent (40%) of the Community Fee in excess of $500”. LPA interviewed Administrator on 10/10/22 who stated although R1 moved out on 7/19/22 they did not provide a proper 30-day notice until 7/19/22 with a move out date of 8/19/22. However, the admission agreement and health and safety code state that the resident is entitled to a 40% refund if the resident leaves for any reason “during the third month of residency.” R1 left the facility during their third month of residency. Therefore the allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D) Exit interview conducted. Report, Deficiencies, Civil Penalty, and Appeal Rights issued via email. 1.1. Basic Services included in the Net Monthly Fee…1.1.11. Transportation, as scheduled, to local shopping, banks, grocery stores and medical appointments in Santa Maria and the surrounding vicinity.” LPA interviews with Administrator regarding transportation indicated the facility will arrange transportation to appointments on Tuesday and Thursday and if the driver was unavailable, the activities director can transport residents. Administrator stated that if the facility is unable to transport a resident, they may contact the family to see if they can transport the resident. The facility does not have a transportation schedule or log showing rides given. Based on the investigation, there is insufficient evidence to prove this allegation, therefore it is deemed Unsubstantiated at this time. LPA advised the facility that the facility is required to arrange transportation to medical appointments for residents, and recommended updating their transportation plan to ensure they are compliant with regulations. Exit interview conducted, copy of report emailed to the Administrator.the state’s words, verbatim · CDSS document, Oct 28, 2022 · control 29-AS-20221004131630

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Nov 4, 2022

87464(d) Basic Services. …If a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal ...either directly or through outside resources. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section when R1's needs were not met, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2022

Plan of correction: Administrator agreed to submit a plan to ensure all residents receive their Basic Services by 11/04/2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(6) · Plan of correction due date: Nov 4, 2022

87507(g)(5)(E)(2)(c) Admission Agreements. A refund of at least 40 percent of the preadmission fee in excess of $500 shall be provided if the resident leaves the facility for any reason during the third month of residency. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section when R1 was not given a 40 percent refund, which posed a potentail health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2022

Plan of correction: Administrator agrees to provide a refund to R1. Administrator will provide proof a refund was issued to CCL by 11/04/2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Olson conducted an on-site 1 year infection control annual visit to the facility above on 08/31/2022 at 10:00 AM. LPA met with Wellness Director Amy Bowman and explained the purpose of the visit. LPA took a physical plant tour of the facility with Wellness Director. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening for all staff and visitors wanting to come into the facility. All documentation is kept in a file. The entry station has hand sanitizer along with a thermometer. The facility has multiple areas spaced to accommodate as much space as possible for social distancing. All equipment and PPE supplies are kept in the storage closets. Medications are kept in a locked medication room. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Wellness Director is in charge of infection control and provides training and education to staff, residents and visitors. Continued 809-C If any suspected or confirmed cases of Covid-19 are found in the facility a staff will use full PPE with N95 masks, face shield, gloves, and gowns when dealing with any residents. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. PPE supplies will be located right outside isolation rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. Facility has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in secured offices or med rooms. 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. Administrator Certificates are valid. Fire extinguishers were charged and inspected annually. The facility has hardwired smoke alarms and carbon monoxide detectors through out the facility. At approximately 4:40 pm, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined there are 2 staff members currently working in the facility and have not been associated to the facility prior to their employment. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D) Exit interview conducted. Report, Deficiencies, Civil Penalty, and Appeal Rights issued via email.the state’s words, verbatim · CDSS document, Aug 31, 2022

Type of visit: Office

An Informal Conference was conducted today via Teams. The purpose of the Informal Conference was to discuss the multiple complaints received and deficiencies cited for Santa Maria Terrace. Present at today’s meeting were: Kelly Burley, Licensing Program Manager (LPM); Jeannette Olson, Licensing Program Analyst; Joanna Enriquez, Administrator; and Amy Bowman, Wellness Director. The Informal Conference process was explained to the Administrator. The Administrator was notified that this Informal Conference is a part of the Administrative Action process and that further citations may result in Probation or a formal Non-Compliance Plan, which could then lead to a referral to the Department's Legal Division for possible Administrative Action. Today's conference addressed the following issues: - Staffing - Meeting the residents’ needs (showering, diapering needs, and call buttons) - Incontinence supplies - Physical plant - Reporting - COVID-19 Protocols LPM Burley encouraged the Administrator to check the Provider Information Notices (PINs) on CCLD's website (www.ccld.ca.gov) to stay up to date on guidance. LPM Burley also discussed the Administrator’s presence in the facility, and that the Administrator was helping at another facility multiple times per week. Administrator stated they are no longer going to the other facility multiple times a week, and have implemented the Wellness Director as a back-up designee if the Administrator is absent from the facility. Exit interview. Report emailed for signaturethe state’s words, verbatim · CDSS document, Aug 2, 2022

Allegation investigated: Staff not maintaining residents hygiene. Staff not providing assistance to residents.

Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the initial investigation, reviewed facility documents and conducted interviews with staff and residents. LPA Diaz interviewed clients on 09/27/21, 9/30/21, and 10/5/21. LPA Diaz interviewed staff on 9/15/21, 9/27/21, 9/28/21, 10/5/21, and 10/6/21. LPA Olson requested and reviewed R1’s admission agreement, physician’s report, preadmission appraisal, assessment, care plan, July and August 2021 Shower Schedule, and ledgers provided. LPA Olson reviewed records, interviewed staff on 5/16/22. LPA Olson interviewed staff and residents on 5/22/22 and 6/6/22. On the allegation: Staff not maintaining residents hygiene. Reporting party stated that R1 was not showered for a month. LPA interviewed staff which revealed that R1 would refuse showers a lot but once a shower chair was provided by the family, they refused less. Family interviews revealed that the facility didn’t ask for a shower chair until 2-3 weeks after admission and after R1 refused showers. Continued on 9099-C Substantiated After they provided a shower chair, the facility said that they had an extra one that was already provided. LPA Olson reviewed R1’s Resident Appraisal and Needs and Services Plan which state that R1 would receive showers twice a week. LPA reviewed July 2021 shower schedule which indicated that R1 refused a shower 7/6/21 and 7/22/21 and was only showered once on 7/27/21 since moving in on 7/5/21. LPA interviewed the Wellness Director at the time who stated they showered Resident 1 at least once in July but didn’t track it. Per the needs and services plan, the resident was not showered twice a week to meet their needs. Based on LPA interviews and record review the allegation is deemed Substantiated at this time. On the allegation: Staff not providing assistance to residents. Reporting Party (RP) stated that R1 would use the provided pendant to call for assistance. RP provided an example that R1 would use their pennant to call staff while on the toilet, yet staff wouldn’t respond. RP stated that family would have to call the facility directly, and receptionists would page care staff to go and assist R1. LPA interviewed 2 Facility Receptionists who confirmed that family’s and residents call the front desk often to ask for care staff to be paged for assistance due to staff not responding to their pennant timely. Staff interviews confirmed they are paged multiple times per shift by the receptionist to assist residents. LPA reviewed call logs from 7/13/21-7/16/21 and 8/3/21-8/6/21 which revealed R1 pressed their pendant a total of 60 times. 24/60 (40%) of R1’s calls were answered in 15 minutes or less, which all staff confirmed is the facility’s goal response time. 12/60 (20%) of R1’s calls were answered within 16-29 minutes, 4/60 (6.6%) of calls were answered within 30-45 minutes, and 20/60 (33.3%) of R1’s calls were not answered at all (remained unanswered). Based on staff and resident interviews, most felt there was not enough staff to meet the resident’s needs and respond timely to the call buttons. Based on LPA interviews and record review the allegation is deemed Substantiated at this time. Exit interview, report given, deficiencies cited on 9099-D, Civil Penalty of $250 is assessed for repeating the same violation within 12 months, appeal rights given. RP stated that maybe R1 needed more care but the facility never informed them. RP stated they had to call the facility for updates and ask what was going on. R1’s physician’s report dated 7/1/21 indicates a diagnosis of hypertension, hypercholesteremia, mild cognitive impairment, needs assistance with bathing, needs minimal assistance with dressing/grooming. R1’s Resident Appraisal dated 7/6/21 indicates R1 uses a walker, needs stand by assistance for transfers for safety, needs stand by assistance for transferring to the toilet, needs physical assistance with bathing twice a week, needs stand by assistance with dressing and needs clothing set up, and needs frequent checks to ensure safety. All staff interviewed stated they try to provide assistance to residents as quickly as possible and respond to call buttons as quickly as possible. Most residents interviewed stated staff provided assistance to meet their needs. A care note for R1 from 7/15/21 at 5:40am indicates a med tech responded to R1’s call and was observed sitting on the bathroom floor with no visible injuries, but was confused, so staff called 9-1-1. The resident left the hospital in stable condition with no injuries but some confusion. An Incident Report indicates on 8/5/21 at 11:45pm, R1 was observed on the floor by staff during a check. R1 complained of back pain and 9-1-1 was called for medical attention. The facility was unable to provide detailed care notes for R1 showing that frequent checks were completed. The electronic system staff use to track resident needs and the care provided only prompts once per shift, and not multiple times per shift; therefore there are no records showing how often each care task was performed. Based on the evidence obtained, there was insufficient evidence to substantiate the allegation that a lack of assistance resulted in a fall. Therefore the allegation is deemed unsubstantiated at this time. An Advisory Note for Technical Assistance was issued to recommend implementing a system that has more accurate data for tracking care completed. Exit interview, Technical Assistance issued, report emailed.the state’s words, verbatim · CDSS document, Jul 11, 2022 · control 29-AS-20210909131131

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 12, 2022

87411(a) Personnel Requirements- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure there was sufficient staff to meet resident needs which posed an immediate health and safety risk to clients in carethe state’s words, verbatim · CDSS document, Jul 11, 2022

Plan of correction: Administrator agreed to submit updated staffing schedule showing an adequate amount of staff to meet residents needs and respond to call buttons timely.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Jul 15, 2022

87464(d) Basic Services. …If a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal...either directly or through outside resources. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section when R1 did not receive a shower for 22 days after moving into the facility, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2022

Plan of correction: Administrator agreed to implement a plan to document shower refusals and to ensure residents receive the proper number of showers per week.

Allegation investigated: Resident’s diapering needs not met Facility does not have adequate hygiene supplies

Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA requested documents and interviewed staff and residents on 6/22/2022. On the allegation: Resident’s diapering needs not met. The Reporting Partys (RPs) stated the morning shift finds multiple residents soaked with urine and fecal matter. RPs stated the residents’ diapers are so full, they leak onto their clothing and sheets, soaking them. The facility’s protocol is for all staff to check incontinent residents every 2 hours and change their briefs as needed. The facility’s protocol is alsofor NOC shift to do rounds with the morning shift once the morning shift starts. Based on interviews, in June 2022, residents were observed to be very wet during the morning joint-shift checks. Interviews revealed the residents are soaking wet, their clothing is soaking wet, and the sheets are soaking wet. Multiple staff stated this was an indication that the residents were not changed frequently enough during the NOC shift. Continued on 9099-C Substantiated LPA observed multiple photographs of soiled diapers, residents with wet and soiled clothing, and residents laying on wet sheets. Wellness Director stated when she reviewed the photographs, she stated it appeared residents were not changed for over 3-4 hours. LPA reviewed facility’s Plan of Care (POC) Response History documents which indicates staff did not respond to residents incontinence care. Resident 1 was missing a conformation of incontinent need met for one shift on 6/9/22, 6/11/22, 6/12/22, 6/15/22, 6/18/22, 6/19/22, 6/21/22 and 6/22/22. Resident 2 and Resident 3 were missing a conformation of their incontinent needs being met for one shift on 6/11/22, 6/12/22, 6/15/22, 6/18/22, 6/19/22, and 6/20/22. Resident 4 was missing a confirmation of incontinent need met for one shift on 6/11/22, 6/12/22, 6/16/22, 6/18/22, and 6/21/22, Resident 5 was missing a confirmation of incontinent need met for one shift on 6/16/22 and 6/21/22. Resident 6 was missing a confirmation of incontinent need being met for one shift on 6/16/22, 6/17/22, 6/18/22, 6/19/22, and 6/21/22. Resident 7 was missing a confirmation of incontinent need met for one shift on 6/15/22, 6/16/22, 6/19/22, and 6/21/22. Resident 8 was missing a confirmation of incontinent need met for one shift on 6/11/22, 6/16/22, 6/19/22, and 6/21/22. Resident 9 was missing a confirmation of incontinent need met for one shift on 6/11/22, 6/16/22, and 6/21/22. Wellness Director stated they held a meeting with staff to address the diapering issues on 6/14/22 at 2pm for 30 minutes. A follow-up meeting was held on 6/27/22 at 2pm to address the issue again. Wellness Director stated they also addressed the issue with the NOC staff. Based on interviews, record review, and photographs, the allegation is deemed Substantiated at this time. On the allegation: Facility does not have adequate hygiene supplies. The RP stated staff take briefs and wipes from other residents when residents run out of supplies and the facility staff do not restock them. Multiple staff interviewed indicated hospice residents do not have enough briefs and they take brief from other residents. Multiple staff stated they notify the med tech the resident is out of briefs, but it takes hours for the med tech to restock the briefs. Some staff stated there is also a delay in receiving briefs when notifying hospice more briefs are needed. Wellness Director admitted it’s difficult for hospice residents to get restocked with briefs and wipes. Based on interviews, the allegation is deemed Substantiated at this time. Exit interview, deficiency cited on 9099-D, report emailed, appeal rights emailed.the state’s words, verbatim · CDSS document, Jul 11, 2022 · control 29-AS-20220616140521

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jul 12, 2022

87625(b)(3) Managed Incontinence...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on record review, interviews and photographs, the licensee did not ensure residents’ incontinence was properly managed, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2022

Plan of correction: Wellness Director held an all staff training on 6/14/22 and 6/27/22 which reviewed team building and incontinent care and provided a sign in sheet to CCL. Wellness Director scheduled Central Coast Home Health for an additional incontinent Care training scheduled on 7/19/22. The POC was cleared during the visit

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3) · Plan of correction due date: Jul 22, 2022

87307(a)(3) Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure residents’ incontinence care products were readily available to each resident when needed, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2022

Plan of correction: Administrator agreed to create a plan to ensure residents’ incontinence care products are reordered and restocked timely.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Olson conducted an unannounced case management visit to issue a deficiency. LPA Olson received multiple Incident Reports (IR) from the facility that were sent after the required 7-day time frame. LPA provided courtesy reminder emails to the Administrator on 3/30/2022, and to the Administrator and Wellness Director on 5/27/2022. LPA continued to receive Incident Reports late, including: · On 6/7/2022, LPA received IRs from 5/22/2022 (16 days after incident), and from 5/18/2022 (14 days after incident). · On 6/23/2022, LPA received IRs from 6/15/2022 (8 days after incident), 6/14/2022 (9 days after incident), 6/13/2022 (10 days after incident). · On 6/29/2022 LPA received IRs from 6/19/2022 (10 days after incident), 6/18/2022 (9 days after incident) and 6/17/2022 (8 days after incident). Based on the information obtained, the facility is cited for late reporting. Exit interview, report given, deficiency cited on 809-D, appeal rights given.the state’s words, verbatim · CDSS document, Jul 11, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jul 15, 2022

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 was not met as evidenced by: Based on record review, the licensee did not ensure incident reports were sent within 7 days of the occurrence on multiple occasions, which posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2022

Plan of correction: The Administrator agreed to do the following: Review Regulation 87211 and submit a Statement of Understanding, detailing how the licensee plans to maintain voluntary compliance. Submit statement no later than 7/15/22.

Allegation investigated: Staff not following COVID-19 protocols Staff does not respond timely to resident calls for assistance Facility does not have adequate staff Resident bathroom has a water leak Facility is in disrepair

Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA interviewed residents on 04/5/2022 and 5/20/2022, and 6/6/22. LPA interviewed staff on 04/5/2022, 5/16/2022, 5/20/2022, and 6/6/22. LPA reviewed call button longs, security footage, guest sign-in logs, maintenance and housekeeping room checklist, and pictures of R1’s apartment upon move in. On the allegation: Staff not following COVID-19 protocols. It was alleged that visitors were not required to wear masks and staff checked guest’s temperature and signed the guest in, but didn’t inquire about vaccination status as required by the guidance at the time of the complaint. Allegedly one guest was unvaccinated and allowed to walk around the facility without a mask and without providing a negative COVID test 3/19/22-3/24/22. On 5/16/22 LPA Olson attempted to view surveillance footage but the system only saves 35 days of footage. LPA did view a sample of 4 hours of footage from 5/7/22 and 4 hours of footage from 5/8/22. Continued on 9099-C Substantiated LPA observed guests arriving with masks on and temperatures being taken. Guests were at the front desk for an average of 30-60 seconds. LPA did not observe any guests take out their phone or wallet to show proof of vaccination or a negative COVID-19 test. LPA observed one child around age 7 or 8 arrive and no paperwork was shown or COVID-19 test administered. LPA viewed visitor logs from 3/19/22-3/24/22 and 5/6/22-5/8/22. Logs did not specify if the individual was vaccinated and showed proof, provided a negative COVID-19 test, or was tested at the facility. PIN 21-40-ASC dating 8/27/21 states that licensees must obtain and track documentation of vaccination or COVID-19 diagnostic test of visitors in order to visit indoors. Verification and record keeping shall take effect on 9/9/21 in accordance with the State Public Health Officer Order. The PIN states “Facilities must have a plan in place for tracking verified visitor vaccination status or documentation of a negative COVID-19 test. Documentation of the verification must be kept on file at the facility and made available upon request to CDSS, or to the local health jurisdiction for purposes of case investigation. Visitors for whom vaccine status is unknown or documentation is not provided, must be considered unvaccinated or incompletely vaccinated.” PIN 22-07-ASC updated 2/7/22 adds that unvaccinated visitors who visit consecutively are required to show a proof of a negative test every third day. Based on the information obtained, the allegation is deemed Substantiated at this time. A Technical Violation Notice Issued. Administrator agreed to redo the sign in sheet and track this data per PIN 21-40-ASC and PIN 22-07-ASC. On the allegation: Staff does not respond timely to resident calls for assistance. It was alleged that Resident 1 (R1) and their family pressed the pendant for help but no one came in a timely manner. LPA Olson reviewed call logs from 3/22/22-3/25/22. Records indicated R1 made a total of 7 calls. Pages go out to staff for around 5 minutes then automatically send a page out again up to 9 more times until the call is answered. Staff responded under 15 minutes to R1's call 3/7 times. Staff responded 15 minutes or longer 4/7 times, with one call not being responded to all. Records indicate on 3/22/22 at 5:40 PM R1's penant rang 9 times, and states “response required but not received as of 6:25p This alert was never responded to.” On 5/20/22, the administrator and staff interviewed stated the staff strive to respond to calls within 15 minutes or less. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility does not have adequate staff. It was alleged that a resident was found wandering the halls and it took time to find a staff to respond. It was alleged that Staff 1 (S1) told R1’s family member that she was working alone that day and had no help. Continued on 9099-C (2) LPA Olson interviewed staff who stated that usually there are 2 staff covering all residents. 4/5 care staff interviewed stated 2 staff was not enough to assist all residents. Staff stated residents with dementia require more attention and that there should be more staff to assist residents because there is a lot of work to do. In March 2022 the facility had 29/91 residents with dementia, 55/91 cannot leave the facility unassisted, 6/91 are on hospice, 12/91 Wander, and currently 1/94 residents need two person assistance (temporarily from 4/20/22- present), 10/94 need transfer assistance, 5/94 are bedridden, 43/94 are non-ambulatory, 16/94 are incontinent, and 11/94 require restroom assistance. 10/14 residents stated that there is not enough staff to assist residents and staff take a long time to respond when they need assistance. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Resident bathroom has a water leak. It was alleged that R1’s bathroom had a water leak and the ceiling had water pouring down and staff responded, “this happens all the time”. LPA Olson interviewed staff and residents that confirmed this happens when an upstairs resident’s toilet overflows or if the resident forgot to place their shower curtain the correct way and the water leaks down to the apartment below. Administrator stated “it is an old building, so it happens”. Facility Maintenance Director confirmed the water leaks through to the apartment below through the toilet if it is not sealed. Based on the information obtained, the allegation is deemed Substantiated at this time. On the allegation: Facility is in disrepair. It was alleged that R1’s carpet tiles were dirty; the baseboards, shower head, facial tissue cover and fridge were covered with mold and hair; the toilet had a yellow ring and crusted urine and mold in the toilet seat bolts. LPA observed pictures from the reporting party and observed a yellow ring around the toilet as well as stains on the carpet and inside the fridge. LPA requested room checklist logs from the last 5 move-ins which show what was done prior to residents moving in. Facility could only produce 2/5 logs and calendar reminders/notes from housekeeping for the other 3 rooms. Three staff interviewed stated that all 5 rooms were cleaned and checked by sales, maintenance and housekeeping. One staff stated that they could have done better and the other two stated that management was informed of the condition of R1’s toilet, fridge, and floor prior to R1 moving in. Interviews revealed the toilet and fridge was replaced after R1 moved in. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview, deficiencies cited on 9099-D, Technical Violation issued, report emailed, appeal rights emailed.the state’s words, verbatim · CDSS document, Jun 6, 2022 · control 29-AS-20220328112002

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 7, 2022

87411(a) Personnel Requirements- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. T his requirement was not met as evidenced by: Based on interviews, and documentation the licensee did not ensure there was sufficient staff to meet resident needs which posed an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jun 6, 2022

Plan of correction: Administrator agreed to create a plan to ensure there is adequate staff to meet residents needs and to respond to call buttons timely and will send a copy of the plan to CCL by 6/7/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e) · Plan of correction due date: Jun 7, 2022

87303(e) Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained. This requirement was not met as evidenced by: Based on interviews and observation, the licensee did not ensure toilets and bathrooms were properly sealed, allowing water to leak to the apartment bellow, which posed an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jun 6, 2022

Plan of correction: Administrator agreed to create a plan to ensure all facility toilets are properly sealed and will send a copy of the plan to CCL by 6/7/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(6) · Plan of correction due date: Jun 10, 2022

87303(e)(6) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on interviews and observation the licensee did not ensure R1’s room was clean and sanitary upon move in which posed a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jun 6, 2022

Plan of correction: Administrator agreed to create a new plan to ensure rooms are clean and ready to move into prior to admission and will send a copy of the plan to CCL by 6/10/22.

Allegation investigated: Staff did not respond to residents calls for help

Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the initial investigation, reviewed facility documents and conducted interviews with staff and residents. LPA Diaz interviewed clients on 08/28/21. LPA Diaz interviewed staff on 8/22/21 and 8/24/21. LPA's reviewed R1’s admission agreement, physician’s report, preadmission appraisal, assessment, care plan, and ledgers provided. LPA Olson reviewed records, interviewed 2 staff on 5/16/22, 2 staff and 5 residents on 5/20/22, 2 staff and 6 residents on 6/6/22. On the allegation: Staff did not respond to residents calls for help. It was alleged that staff arrived late or didn’t respond at all to a resident’s call button. 10/12 residents interviwed stated staff do not respond to calls timely. LPA Olson reviewed call logs from 6/1/20 through 6/4/20. Records show a total of 96 residents used their call button which rang 1-9 times between 6/1/20 starting at 7:30 PM until 6/4/20 8:50 AM. Continued on 9099-C Substantiated 32/96 (33%) resident calls were answered in less than 10 minutes, 28/96 (29%) resident calls were answered in 10-20 minutes, 11/96 (11%) resident calls were answered in 21-45 minutes, 25/96 (26%) residents button rang over 9 times and was never responded to. On 5/20/22, the administrator and staff interviewed stated the staff strive to respond to the call within 15 minutes or less. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview, deficiency cited on 9099-D, report emailed, appeal rights emailed. R1’s physician’s report dated 3/21/2019 indicates R1 can self bathe when R1’s pain is controlled, R1’s pre-admission appraisal indicates standby assistance for showers and R1’s assessment indicates stand by assistance with bathing every other day and was signed by R1 on 4/16/2019. R1’s care plan indicates R1 needed physical assistance with bathing twice weekly the Administrator stated R1 typically would not shower unless staff assisted R1 with it, despite claims R1 had already showered. R1 refused bathing assistance in July and August 2019. Based on the information obtained, the allegations are deemed unsubstantiated at this time. On the allegation: Staff mismanaged residents medications. It was alleged that Resident 1 (R1) complained on numerous occasions of the inconsistency in receiving medications. LPA Olson reviewed R1’s Medication Administration Record (MAR) from January 2020 through September 2020. July 2020 MAR records indicate on 7/1/20, a 6AM dosage of tramadol-Acetaminophen Tablet 37.5-325 MG was left blank, staff interviewed stated the resident received that medication at 12:10 AM as a PRN, therefore the AM dose was not given, although a code/note should have been attached. The MARs indicated other reasons why medications were not given between January and September 2020, including refusals, orders to hold, medication awaiting delivery, and away from facility. Although one entry on the MAR is missing, there is insufficient evidence to prove that R1’s medication was mismanaged. Due to a lack of evidence, the allegation is unsubstantiated at this time. On the allegation: Facility overcharged resident for services. It was alleged that Resident 1 (R1) was overcharged for bathing and medication assistance, and was overcharged for a month of care before moving out. 7 out of 7 residents interviewed in 2021 stated that they have no issues receiving services at the facility or and have no problems with refunds. 2 residents stated that they requested the facility to remove specific services that they no longer need, and the facility complied with their requests. R1 was charged for medication assistance in November and December 2019. The Administrator stated when a resident is in the hospital, they stop charges for care but they still charge for medication management because the resident still has medications at the facility even if they are PRN medications. The Administrator stated the staff still count the medications including PRNs everyday, and so therefore still charge for medication assistance unless the resident does not have any medications present in the facility. This is also stated in the admission agreement on page 8 under “Absence from the Community.” Continued on 9099-C This is an amended report R1 and their responsible party both signed the admission agreement on 4/19/2019. R1 was moved from the facility in September 2020 and provided a written 30-day notice on 9/25/2020. R1’s belongings were removed by 9/28/2020. The September 2020 fees were already paid on 9/10/2020, before R1 moved out. The October 2020 fee consisted of a pro-rated room rate only since no care was provided in October. LPA Olson reviewed the records and determined the facility did not charge for anything after the 30-day notice was up. Based on the information obtained, the allegation is deemed unsubstantiated at this time. On the allegation: Resident is not treated with dignity by staff. It was alleged that Resident 1 (R1) experienced rude behaviors from caregivers like leaving food trays by the door and not placing it by their bedside table, and caregivers would not open the window blinds without being asked. LPA interviewed 12 residents who lived in the facility in 2020. 10/12 residents stated they were treated well and with dignity by staff. Resident 2 (R2) stated staff answered their call buttons eventually but do not assist with the tasks R2 called for, including losing remotes, changing the room temperature, help getting to the bathroom and showers. Staff confirmed they respond to R2’s calls but prioritize other tasks over non-essential tasks R2 asks for. Based on the information obtained, the allegations are deemed unsubstantiated at this time. An advisory note for Technical Assistance is issued to ensure all staff respond appropriately and with dignity to resident’s and their calls. Exit interview, Technical Assistance issued, report emailed.the state’s words, verbatim · CDSS document, Jun 6, 2022 · control 29-AS-20201217132859

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 7, 2022

87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above section when they had inadequate staff to respond to call buttons, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 6, 2022

Plan of correction: Administrator agreed to create a plan to ensure there is adequate staff to respond to residents timely and will send a copy of the plan to CCL by 6/7/22.

Allegation investigated: Staff are not providing authorized representative with resident records Staff are not returning authorized representative's calls/emails

Licensing Program Analyst (LPA) Olson and Licensing Program Manager (LPM) Burley conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the investigation, reviewed facility documents and conducted interviews with the staff and residents. LPA interviewed staff on 2/10/22 at 4:22pm and Wellness director at 4:40pm. LPA interviewed residents on 2/11/22 at 4:19pm. On the allegation: Staff are not providing authorized representative with resident records. Based on an interview with the Administrator, the local Public Health Department held an onsite COVID-19 vaccine clinic at the facility. After vaccines were given to the residents, the Health Department provided the residents with their vaccination cards. The vaccination cards indicated the type of vaccine and the date that the vaccine was administered to the resident. The Administrator stated the facility did not collect or hold the vaccination cards and instead each resident held onto to their own vaccination card. However, the facility collected the data from the vaccination cards and logged the data within facility records. Continued on 9099-C Unsubstantiated The Wellness Director also confirmed that the vaccination data has been stored within facility records. The Administrator stated, the facility would release medical documents to any authorized representative. The Administrator stated that Resident 1 (R1) moved into the facility on 2/22/21 and R1 moved out of the facility on 3/30/21. R1 received the first vaccine dose on 2/24/21, and R1 did not receive the second vaccine while staying at the facility. The facility was never contacted by an authorized representative in search of medical or vaccine records. The LPA attempted to contact the reporting party (RP) 3 times via telephone and email. LPA was unable to reach the RP for each attempt made and the RP did not return calls or emails. Based on the interviews and records reviewed, the allegation is deemed unsubstantiated at this time. On the allegation: Staff are not returning authorized representative's calls/emails. According to the Administrator, the Wellness department and the Administrator were never contacted by a resident’s authorized representative in search of medical or vaccine records. The Administrator also stated that they did not receive any emails or calls from R1’s responsible party requesting vaccine or medical records. The Wellness Director confirmed that the facility has not been contacted by R1’s representative or any family representatives requesting vaccination records. The LPA attempted to contact the Reporting Party (RP) 3 times via telephone and email. LPA was unable to reach the RP for each attempt made and the RP did not return calls or emails. Based on the interviews and records reviewed, the allegation is deemed unsubstantiated at this time. Exit interview, report given.the state’s words, verbatim · CDSS document, Mar 10, 2022 · control 29-AS-20211019091255

Allegation investigated: Facility is not following its Admission Agreement on refunds Facility staff did not keep residents’ room clean

Licensing Program Analyst (LPA) Olson and Licensing Program Manager (LPM) Burley conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the investigation, reviewed facility documents and conducted interviews with staff and residents. LPA interviewed clients on 08/28/2021 at 2:57pm, 3:06pm, 3:14pm, 3:20pm, 3:31pm, 3:37pm, and 3:50pm. LPA interviewed staff on 8/22/21 at 5:38pm, and 8:23pm at 6:07pm. LPA interviewed staff on 8/24/21 at 8:34am, 2:38pm, 3:21pm and on 8/2821 at 2:13pm. LPA reviewed R1’s admission agreement, physician’s report, preadmission appraisal, assessment, care plan, and ledgers provided. LPA Olson intervied 2 staff on 3/10/22 and reviewed records. Continued on 9099-C Unsubstantiated On the allegation: Facility is not following its Admissions agreement on refunds. It was alleged that Resident 1 (R1) was overcharged for bathing and medication assistance, and was overcharged for a month of care before moving out. 7 out of 7 residents stated that they have no issues receiving services at the facility or do they have problems with refunds. 2 residents stated that they requested the facility to remove specific services that they no longer need, and the facility complied with their requests. R1’s physician’s report dated 3/21/2019 indicates R1 can self-bathe when R1’s pain is controlled, and can handle their own medications except if using excess pain medication. R1’s pre-admission appraisal indicates standby assistance for showers and facility will store, manage and help with self-administration of medications and was signed by R1 on 4/16/2019. R1’s assessment indicates stand by assistance with bathing every other day, and for staff assistance with medication, and was signed by R1 on 4/16/2019. R1’s care plan indicates R1 needed physical assistance with bathing twice weekly and for staff assistance with medication. Although R1 refused staff assistance with bathing on multiple occasions, the Administrator stated R1 still needed assistance with bathing due to R1’s physician’s report and care plan, which was agreed to by R1. The Administrator stated the safest way for R1 to shower was with staff assistance. The Administrator stated R1 typically would not shower unless staff assisted R1 with it, despite claims R1 had already showered. R1 refused bathing assistance in July and August 2019 but was still charged for it, because R1’s physician indicated R1 needed assistance with bathing and R1 signed their care plan agreeing to shower assistance. R1 was charged for medication assistance in November and December 2019. The Administrator stated when a resident is in the hospital, they stop charges for care but they still charge for medication management because the resident still has medications at the facility even if they are PRN medications. The Administrator stated the staff still count the medications including PRNs everyday, and so therefore still charge for medication assistance unless the resident does not have any medications present in the facility. This is also stated in the admission agreement on page 8 under “Absence from the Community.” R1 and their responsible party both signed the admission agreement on 4/19/2019. R1 was moved from the facility in September 2020 and provided a written 30-day notice on 9/25/2020. R1’s belongings were removed by 9/28/2020. The September 2020 fees were already paid on 9/10/2020, before R1 moved out. The October 2020 fee consisted of a pro-rated room rate only, since no care was provided in October. LPA reviewed the records and determined the facility did not charge for anything after the 30-day notice was up. Based on the information obtained, the allegations are deemed unsubstantiated at this time. Continued on 9099-C On the allegation: Facility staff did not keep residents’ room clean. 7 out of 7 residents stated that the facility is kept clean by the caregivers and housekeepers. The residents stated staff dust, sweep, mop, vacuum floors, wash bed sheets, remove trash, and help organize resident’s rooms. The resident’s laundry and the resident’s rooms are cleaned once a week. The residents also stated that the bed sheets smell good after they are cleaned. The staff are frequently cleaning, and all residents interviewed are satisfied with the cleanliness at the facility. According to the staff, caregivers would make beds, clean counter tops, sweep, dust, take out the trash, and clean up accidents. The housekeepers are required perform deep cleanings and use liquid cleaners to clean toilets. The staff confirmed that housekeeping and laundry is done once a week but will also clean rooms if messes occur. According to the staff, R1 would refuse housekeeping and therefore staff would often monitor R1’s room and clean spilt food or old food that was left out. R1 would sleep without R1’s briefs and therefore housekeeping was frequently changing sheets to prevent odors. According to the staff, the housekeepers do a good job and none of the residents have said there are unsatisfied with cleanliness in the facility. LPA observed several different resident rooms to be clean and sanitary. Based on the interviews and observations, the allegation is deemed unsubstantiated at this time. Exit interview, report given.the state’s words, verbatim · CDSS document, Mar 10, 2022 · control 29-AS-20201102131546

Allegation investigated: Facility staff spoke inappropriately to resident Facility staff did not treat resident with respect

Licensing Program Analyst (LPA) Diaz conducted a complaint visit to deliver final findings of the complaint investigation conducted by LPA Diaz. LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed clients on 10/5/2020 and 10/7/2020 between 3:00pm and 5:00pm. LPA interviewed clients on 08/5/2020 between 11:00am and 12:00pm. LPA interviewed staff on 6/11/2020 between 4:00pm and 5:00pm. LPA interviewed staff on 08/6/2020 between 11:28am and 3:30pm. LPA interviewed staff on 09/8/2020 between 2:51pm and 4:00pm. LPA interviewed staff on 11/24/2021 between 3:00pm and 4:00pm. LPA interviewed staff on 12/1/2021 between 3:00pm and 4:00pm. LPA interviewed staff on 12/2/2021 between 1:30pm and 3:30pm. On the allegation: Facility staff speak inappropriately to resident: All staff interviewed stated that they have never heard any verbal abuse or profanity used towards a resident. All staff stated they understand what a mandated is and would report any abuse to their supervisor. 9 out of 9 residents stated that they like living in the facility and the staff are kind. Unsubstantiated All residents interviewed confirmed that they have never witnessed any staff members speak inappropriately towards the residents. Based on the interviews, the allegation that the facility staff speak inappropriately to resident is deemed unsubstantiated at this time. On the allegation: facility staff did not treat resident with respect. 6 out 6 staff consistently explained that Resident 1 (R1) was declining in health and was placed on hospice. 6 out of 6 caregivers described R1 as an anxious bedridden resident that became needy towards the end of their stay at the facility. According to the staff, R1 was always reliant on the caregivers and R1 did not want to be left alone. All staff stated that R1 was given full care at the facility. The caregivers made consistent rounds and provided care to R1. All staff stated that R1 was always treated with respect and dignity. The facility Director observed the caregivers to be patient and treat R1 with respect. R1 would constantly press their call button and staff always responded to R1. 9 out of 9 residents stated that they like living in the facility and are treated with respect. Based on the interviews, the allegation: facility staff did not treat resident with respect is deemed unsubstantiated at this time. Exit interview, report given via email.the state’s words, verbatim · CDSS document, Dec 2, 2021 · control 29-AS-20200331133055

Allegation investigated: Staff did not ensure resident received insulin.

Licensing Program Analyst (LPA) Diaz conducted a complaint visit to deliver final findings of the complaint investigation conducted by LPA Diaz. LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed staff on 09/03/20 at 11:50am,12:30pm and interviewed staff on 7/27/21 at 6:30pm. LPA interviewed staff on 08/04/21 at 3:45pm, 6:00pm at 6:35pm. LPA interviewed staff on 08/05/21 at 3:30pm, 5:30pm 5:46pm 6:51pm. LPA interviewed clients on 08/05/21 at 5:54pm and at 6:03pm. LPA interviewed clients on 08/06/21 at 10:36am, 10:48am, 11:01am, 11:10am, 11:16am, 11:23am and on 08/09/21 at 4:00pm. On the allegation: Staff did not ensure resident received insulin: LPA interviewed residents that are on the medication program at the facility, and 9 out of 9 residents stated that they receive their medications without any issues. 9 out of 9 residents stated MedTech’s are good at providing medication on time or when needed. 3 out of 9 residents stated the facility administers medication on time or within the permitted time window. Substantiated All staff stated that MedTech’s document the medications administered in the medication log. The MedTech’s review the MAR and discuss administered medication, new medication, change of behavior, resident refusing medication, and any resident concerns. 9 out of 9 staff stated there is good communication between MedTech’s during shit changes and as a result very few medication errors occur. Staff 1 (S1) stated, Resident 1 (R1) had left the facility but returned during the night a few days later. Due to lack of communication, the morning MedTech was unaware that R1 returned to the facility and therefore did not provide R1 with their insulin. Later that day, S1 was working in the afternoon and R1 told S1 that they did not receive their insulin in the morning. S1 checked R1 and blood sugar was normal. Since this incident, the facility created a MedTech log that indicates medication administered and the status regarding the resident’s whereabouts. Based on the interviews and observations, the allegation Staff did not ensure resident received insulin is deemed substantiated at this time. Exit interview, deficiency cited on 9099-D, report given, appeal rights given. All staff stated that the facility serves plenty of good quality food and residents are escorted to the dining hall or food is delivered by staff. According to the administrator, breakfast, lunch and dinner were served to the resident’s room during part of the COVID-19 pandemic. There are two server’s that deliver food and beverages to the rooms. The kitchen has checklist/log to indicate when meals are made, and when meals are delivered. The meals are served one floor at a time to ensure that meals are served hot. LPA observed a dinner plate being prepared in the kitchen, and the plate was of substantial size and of good quality. LPA observed fresh fruits vegetables and a variety of meats inside the kitchen freezer. Based on the interviews and observations, the allegation Staff did not provide resident adequate food service is deemed unsubstantiated at this time. Exit interview, report given.the state’s words, verbatim · CDSS document, Nov 16, 2021 · control 29-AS-20200828153423

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 16, 2021

87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced By: Based on medication review, the licensee failed to ensure medications were not given as prescribed for resident 1. (R1) which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2021

Plan of correction: Licensee agreed to submit a plan to licensing about their new medication, status and communication procedures. Plan will be submitted by 11/19/2021 to LPA by email (arien.diaz@dss.ca.gov)

Allegation investigated: Staff administered another resident's medications to resident.

LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed staff on 08/07/2020, at 2:22pm and on 09/11/2020 at 11:19am and 3:09pm. LPA interviewed staff on 10/15/2020, at 4:06pm and on 10/23/2020, at 3:50pm and at 4:21pm. LPA interviewed staff on 10/27/2020, at 4:32pm, 4:56pm, and on 10/29/2020, at 11:39pm. LPA interviewed residents on 09/10/2020, at 3:30pm, 3:55pm, 4:16pm and on 10/21/2020 at 11:40am, 11:51am, 12:18pm, 12:21pm, 12:40pm, and 12:51pm. LPA interviewed complainants on 10/15/220 at 3:39pm and on 10/28/2020, at 9:10am. On the allegation: Staff administered another resident's medications to resident: LPA Diaz interviewed staff regarding this allegation. The Administrator and Wellness Director admitted fault regarding the med error involving (R1) on 5/16/2020. Based on the interviews, the allegation for Staff administered another resident's medications to resident is deemed substantiated at this time. Substantiated Three staff members interviewed also stated there are backup MedTech’s or Caregivers to provide additional support. Administrator can hear all communication among staff from their walkie talkie. 9 of 9 residents stated that the staff consistently checks on them. LPA reviewed the facility’s frequent checklist, and R1 was regularly checked on and documented by staff. Therefore, based on the interviews, and record reviewed the allegation for lack of supervision resulting in resident sustaining multiple falls is deemed unsubstantiated at this time. On the allegation: Resident is not receiving assistance with showers as needed: LPA Diaz interviewed both staff and residents regarding this allegation. All staff consistently stated procedures and experiences when showering residents. All staff stated they follow the shower schedule and have never forgotten to shower a resident. All staff members stated that they document the shower log if residents refuse to shower, therefore the next shift will be aware of residents that need showers. All staff members stated that they are unaware of any showering issues among the residents. The Administrator stated, there have not been any issues with showers, and nothing has been escalated regarding showers. The Administrator is involved and can hear all communication among staff from their walkie talkie. The administrator confirmed that the staff have been good about giving consistent showers with no issues. Incontinent residents stated they are content with the shower assistance and do not have any issues. R1 stated that their shower times are Tuesday and Friday, and shower assistant in the facility is fine. LPA reviewed the facility’s shower log and it confirms R1’s statement. Based on the interviews and records reviewed, the allegation that the Resident is not receiving assistance with showers as needed is deemed unsubstantiated at this time. On the allegation: Facility does not provide food of the quality or quantity to meet the needs of the resident: Staff#1, (S1) explained that meals are served one floor at a time to ensure that meals are served hot. All staff interviewed stated that the facility provides good quality food. The food is warm and delivered immediately. Staff stated, some residents do not eat their food right away and then their food gets cold. The kitchen always provides vegetables, meat, bread and some type of side. All staff interviews confirm that meals are served warm. (S2) stated that the Food Service Director, and R1’s family had a discussion and created a special meal plan for R1. R1 would still reject food from the meal plan and then the facility would bring R1 an additional alternative meal at no cost. 2 of 9 residents interviewed stated the food is not served warm and the food is too dry or too tough to chew. 7 of 9 residents stated that the there is a substantial amount of food served among meals, the quality of food is good, and the food is served warm. 2 residents interviewed stated they have too much to eat and make two meals out of one. LPA observed two residents’ lunches, and both lunches were of good quality and quantity. LPA also observed a plate of food being prepared in the kitchen. The plate was a substantial size and of good quality. LPA observed fresh fruits and vegetables inside the kitchen freezer. Based on the interviews and observations, the allegation Facility does not provide food of the quality or quantity to meet the needs of the resident is deemed unsubstantiated at this time. On the allegation: Resident does not have functioning pendant to alert staff: LPA Diaz interviewed both staff and residents regarding this allegation. LPA had (S1) press a resident’s emergency button as a test, and a different staff member responded to the call in 2 minutes. (S1) stated that the call buttons are never taken away from residents. LPA then interviewed residents and verified that 9 of 9 residents stated that their call buttons always work, and staff responds right away, but sometimes are delayed if other residents are being helped. 3 of 9 residents stated that staff responds quickly to their call buttons within 10 minutes or less. Staff members interviewed stated the response time to assist a resident is within 5 min or less. 4 of 9 staff interviewed stated they have experienced issues clearing the staff pendant, but never experienced malfunctions with residents call button. Issues clearing pendants were escalated to the administrator and fixed the same day. (S2) stated that Informational Technology will be upgrading the facility call system by December 1st, 2020. Based on the interviews and observation, the allegation Resident does not have functioning pendant to alert staff is deemed unsubstantiated at this time. On the allegation: Facility did not provide linens for resident's bed: LPA Diaz interviewed both staff and residents regarding this allegation. (S2) stated that all residents are to bring their own bed linens during the initial entry, but if residents neglect to bring their own linens, the facility will provide the resident with linens. Housekeeping and staff interviewed stated that the resident’s sheets are changed daily, and if sheets become dirty, they are changed with extra sheets that are stored in the resident’s closet. Housekeeping interviewed stated that R1’s sheets are generally changed in the morning and that R1’s sheets are never wet or dirty. 9 of 9 residents interviewed stated that they there are satisfied with linens, the linens are soft and smell good, and confirm that if linens become dirty the staff will change them with spare sheets in the closet. R1 stated that housekeeping is good, R1s sheets are always clean, and they throw away R1s trash every day. Based on the interviews, the allegation Facility did not provide linens for resident's bed is deemed unsubstantiated at this time. On the allegation: Facility is not providing adequate housekeeping services: According to the facility staff, resident rooms are cleaned at least once a week by housekeeping, and the caregivers will clean rooms as needed. The housekeepers clean the floors, restrooms, and wipe down the furniture. The caregivers will clean up spilled drinks or assist with laundry. Housekeeping stated that R1 was hoarding trash in room. Housekeeping and R1’s family explained to R1 that the trash is old and must be thrown away daily. Housekeeping stated that R1 was cooperative and complied and stated there are no issues cleaning R1’s room. Housekeeping cleans R1’s room once a week and empty’s R1’s trash once or twice a day. 9 of 9 residents interviewed stated that the rooms are cleaned once a week and are satisfied with the cleanliness of the rooms. R1 stated that housekeeping is good, my sheets are always clean, and they throw away my trash every day. Interviews with both residents and staff confirm that resident rooms are regularly cleaned. Based on the interviews, the allegation Facility is not providing adequate housekeeping services is deemed unsubstantiated at this time. On the allegation: Facility is charging resident for services resident did not receive: LPA Diaz interviewed residents and staff regarding this allegation. Staff members interviewed stated they follow the shower schedule and have never forgotten to shower a resident. All staff members stated if residents refuse to shower, it is documented in the shower log. Then the next shift will review the log and shower residents that have not showered yet. All staff members stated that they are unaware of any showering issues among the residents. Staff stated we have no issues with showers, and nothing has been escalated to supervisors about showers. Administrator can hear all communication among staff from their walkie talkie and confirmed that the staff have been good about giving consistent showers with no issues. Housekeeping and staff interviewed stated that the resident’s sheets are changed daily, and if sheets become dirty, they are replaced with clean sheets stored in the resident’s closet. Housekeeping stated that R1’s sheets are generally changed in the morning and that R1’s sheets are never wet or dirty. Housekeeping cleans R1’s room once a week and empties R1’s trash once or twice a day. 9 of 9 residents interviewed stated that they there are satisfied with linens, the linens are soft and smell good, and confirm that if their linens get dirty, then the staff will change them with spare sheets in the closet. Incontinent residents confirmed and stated they are content with the shower assistance in the facility and do not have any issues with showering. R1 stated that their shower times were Tuesday and Friday mornings and shower assistant in the facility is fine. R1 confirmed and stated that housekeeping is good, sheets are always clean, and trash is thrown away every day. Interviews with both residents and staff confirm that resident rooms are regularly cleaned. LPA reviewed R1s admission agreement and the services have been provided by the facility. Based on the interviews, the allegation Facility is charging resident for services resident did not receive deemed unsubstantiated at this time.the state’s words, verbatim · CDSS document, Sep 30, 2021 · control 29-AS-20200730152731

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Oct 4, 2021

87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure that resident received the prescribed medicationthe state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Licensee shall ensure that all Medication technicians will attend Inservice training. Licensee shall submit a written plan to CCLD by the due date that states how Licensee plans to ensure that the same error is avoided in the future.

Type of visit: Required - 1 Year

On 8/31/21 at 11:30 AM, Licensing Program Analyst (LPA) Toan Luong contacted Administrator Sanjuana Enriquez to perform a facility risk assessment. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Administrator Sanjuana Enriquez and explained the purpose of the visit. Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility is a Residential Care Facility for the Elderly. During the facility tour, LPA advised posting signs of CDSS PINs and have PINs readily accessible to residents, visitors, and staff. LPA advised Administrator to have Emergency Disaster Plan contact numbers readily available for staff and residents as it was posted in a frame behind page 1 of LIC 610E. Administrator posted CDSS PINs and displayed contact information from LIC 610E prior to LPA's departure. LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Administrator to satisfaction. LPA reviewed staff roster and noted an individual was working without CDSS clearance. LPA issued an immediate citation. Exit interview was conducted. No other deficiencies were cited. Report and appeal rights emailed to Administrator.the state’s words, verbatim · CDSS document, Aug 31, 2021

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.