Aaa Kindness Care II

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 1/19/2023 around 09:50 AM. LPA met with Shayna Pettiford, Administrator and explained the purpose of the visit. LPA took a physical plant tour of the facility with Administrator. The facility has submitted an Infection Control Plan to the department. The facility has an entry point at the front door where everyone entering completes temperature screening on all staff and visitors wanting to come into the facility. The entry station has hand sanitizer along with a thermometer. The staff screen residents for symptoms and temperature once to twice a day. 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 in the front door and entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility and on outings into the community. All staff will wear face coverings in the facility and when on outings with residents. Facility has 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. Administrator and Health Services Director is in charge of infection control and provides training and education to staff, residents and visitors. Staff will use full PPE with N95 masks and face shields when working with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for residents so isolation can be arranged when and if needed. The facility has single and double rooms that are disinfected and wiped down daily. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Continued on 809-C Facility has plans for delivering medications and meals to any quarantined/isolation resident rooms. Facility Administrator 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. 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, and paper towels. Staff and resident records are kept in a locked office. 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. Administrator Certificate is valid. Fire extinguishers was charged and inspected annually. The facility has working smoke and carbon monoxide detectors throughout the facility. At approximately 11:30 am, LPA reviewed Guardian/ Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined that all staff are fingerprint cleared and associated to the facility. No deficiencies observed during the visit and all infection control protocols are implemented and are being followed. Exit interview completed and a copy of report was emailed to Administrator/ Licensee.the state’s words, verbatim · CDSS document, Jan 19, 2023

Allegation investigated: Facility not providing a comfortable temperature for residents in home.

Licensing Program Analysts (LPA's) Olson and Cortez conducted an initial complaint investigation for the allegation listed above. LPA's arrived at the facility at 11:00 AM and met with Sheryll Ann, Health Services Director. Administrator arrived around 11:15 AM. LPA's toured the inside and outside of the facility with Administrator. LPA's interviewed residents between 11:10 AM and 12:0 0PM, a staff around 11:34 AM and Administrator around 12 PM. LPA's reviewed and obtained copies of pertinent documents. During the facility tour and upon arival LPA's noticed the facility temperature was very warm. Interviews revealed only part of the facility has air conditioning. LPAs measured 12 room tempurates between 11:20 AM and 11:50 AM. The sun room was 86.2, Resident 1 room (R1) was 86.5, Resident 2- 89.2, Resident 3- 87.2, Resident 4- 86.9, Resident 5- 79, Rec room was 84.7, Resident 6- 84.9, Resident 7- 84.4, Activities Room- 79.8, Hall 78.1, and Resident 7- 79.2. Continued on 9099--C Substantiated It was alleged that residents rooms were over 93 degrees this week and was not a comfortable temperature. LPA's observed the temperature outside at 85 degrees Fahrenheit upon arrival to the facility. LPA's confirmed that has been an excessive heat warning throughout the area issued at this time. LPA's thermometer readings varied between 78.1 degrees and 89.2 degrees Fahrenheit. Based on observation, The allegation that Facility not providing a comfortable temperature for residents in home is deemed SUBSTANTIATED at this time. Administrator Interview revealed that once they were made aware of the hot temperature in a residents room they immediately got a fan for the resident and called stores to find an AC unit. Administrator stated that an hour after they were informed a portable AC unit was delivered to the room to cool it down. Administrator also stated that the facility is doing frequent checks on residents, reminding them to stay hydrated and encouraging them to do activities and hang out in the sunshine room that has air conditioning. 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, a copy of reports and appeal rights were reviewed and provided to the Administrator via email.the state’s words, verbatim · CDSS document, Sep 8, 2022 · control 29-AS-20220907122927

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b) · Plan of correction due date: Sep 9, 2022

87303 (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C)... This requirement is not met as evidenced by: Based on observation the temperatures inside the facility measured as high as 89 degrees Fahrenheit, which poses an immediate health, safety and personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Sep 8, 2022

Plan of correction: Administraor Agreed to create a plan to ensure the facility rooms are at a comforatble range bellow 85 degrees and submit the plan to CCL by 9/9/22. Administraor will send updates to LPA on facility temperature around 3 PM every day for the next 3 days.

Allegation investigated: Staff allowed resident to leave the facility with an unauthorized person

LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed staff on 01/05/2022 at 5:42pm and 6:21pm and on 01/06/2022 at 5:17pm and 6:30pm. LPA interviewed staff on 01/09/22 at 11:50am, 12:14pm, 1:02pm, and 5:03pm. LPA interviewed staff on 01/10/22 at 11:09am. LPA interviewed residents on 01/10/22 between 1:00pm and 2:30pm. On the allegation: Staff allowed resident to leave the facility with an unauthorized person. 8 out of 8 staff stated they understand what a mandated reporter is and would report any abuse to their administrator or the Licensing agency. All staff stated the procedures for when residents leave the facility, and that the resident’s responsible party calls the facility and discusses the details about the residents outing or medical appointment in advance. If residents need to take medication during their outing, the responsible party must sign the medication release form. Substantiated The residents also have chaperones when they leave the facility, and chaperones can be the power of attorney (POA), a family member, or caregivers from the facility. Third party transports are also used to pick up and drive residents to their appointments. However, drivers must have a chaperone to advocate for the resident. The resident appointment is indicated on three calendars located in three different areas in the facility. All staff members can review the calendars, thus are aware of resident appointments. The staff also utilize a phone application to organize and illustrate resident appointments. According to the administrator, resident 1, (R1’s) daughter emailed the administrator about R1’s doctor’s appointment at 12pm. Then the administrator received a follow up text message from R1’s daughter stating that the appointment had been changed to 10/05/2021 at 1:45pm. The text message also indicated that R1s second daughter will be joining R1 and the third-party driver. According to the staff members at the facility on 10/5/21, the driver arrived early at the facility around 11:45am. The driver was screened, checked in and asked to wait on the patio for R1. Staff member 1 (S1) stated they were unaware of the doctor’s apportionment on 10/5/21 but was notified that the driver was waiting on the patio for R1. S1 brought R1 to the driver and then S1 went back inside the facility. The second daughter arrived late at the facility around 12:15pm and was looking for R1. The administrator immediately called the driver and had them return to the facility. The staff stated there was a miscommunication between S1 and the driver and as a result the driver took the resident without a chaperone. According to the administrator, the facility would never let R1 attend appointments alone. R1 is nonverbal and has dementia. The Administrator provided the LPA with a copy R1s physician report. LPA reviewed R1s physician report and it indicates that R1 is unable to leave facility unassisted. All verbal residents stated that they are accompanied by someone during outings. Based on the interviews and records reviewed, On the allegation: Staff allowed resident to leave the facility with an unauthorized person is deemed substantiated at this time. Exit interview, report given.the state’s words, verbatim · CDSS document, Jan 27, 2022 · control 29-AS-20211012122707

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 28, 2022

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following...: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 left the facility with an unqualified person to meet the resident needs.the state’s words, verbatim · CDSS document, Jan 27, 2022

Plan of correction: Administrator will ensure that no resident will be released to transport and only to the resident’s responsible party. Administrator will retrain staff regarding outings and apportionments.

Type of visit: Required - 1 Year

At 11:52am, on 1/27/2022, Licensing Program Analysts (LPA) Diaz conducted an unannounced annual inspection of the facility above. LPA informed Administrator, Shayna Pettiford the reason for the visit. The LPA and Administrator toured the facility. At 12:11pm LPA observed all hard-wired smoke alarms and carbon monoxide detectors to be functioning properly. LPA observed all fire extinguishers to be fully charged. Paint, windows, blinds, and floors are in good repair. The common living and dining areas are clean and properly furnished. A working telephone is present. The facility is set at a comfortable temperature. The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food and water is present. A locked medication cabinet and First Aid Kit was observed to be complete. There is space to lock chemicals in the staff laundry room and under the kitchen sink. Sharp items are stored in a locked drawer. LPA also observed adequate supply of PPE, and toilet paper soap and paper towels. LPA Diaz conducted Infection Control mitigation module with Administrator. No other corrections found in the mitigation module. Exit interview conducted and report emailedthe state’s words, verbatim · CDSS document, Jan 27, 2022