A Casa Tunnell

Allegation investigated: Facility retained a resident with a prohibited health condition.

Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial complaint visit was conducted on 06/09/2022 by LPA Jeannette Olson. During today’s visit, LPA met with Administrator/Licensee and explained the reason for the visit. On 06/03/2022, the Department received a complaint regarding an allegation that the facility retained a resident with a prohibited health condition. It was alleged that while under facility care, Resident #1 (R1) developed a stage 4 pressure injury and was not on hospice. On 06/09/2022, between 11:00am and 2:30pm, LPA Olson conducted the initial 10-day complaint visit. The LPA met with Aprilyn Soriano, Administrator/Licensee, and explained the purpose of the visit. LPA toured the facility and interviewed staff. The LPA obtained documents related to R1 and noted further investigation was needed. Continued on 9099-C Substantiated LPA Olson conducted interviews on 06/09/2022 with the Administrator, staff #1 (S1), and Witness #1 (W1); on 06/21/2022, at approximately 11:30am, with Long Term Care Ombudsman (LTCO); and on 06/25/2022, at approximately 1:00pm, with R1’s resident representatives. Additionally, the LPA reviewed copies of Marian Regional Medical Center medical records, Dignity Home Health records, facility records including documents related to R1, and photographs of R1’s pressure injuries. The information obtained from interviews revealed that LTCO visits the facility once a month and would visit R1 every time. The LTCO noted that R1 would usually talk to them but the last 3 months from March 2022 to May 2022, R1 would not wake up or acknowledge LTCO when they walked in. The LTCO observed R1 to always be in bed sleeping, lying on back. The LTCO reported the concerns of R1’s decline to the administrator who stated they were aware and had been trying to get a doctor appointment for R1, but the doctor was on leave, and they was trying to find another doctor. The investigation revealed that on 12/15/2020, R1 was admitted to the facility under the prior facility ownership. The facility had a change of ownership effective 01/12/2022, and the current licensee /administrator, Aprilyn Soriano, became the new facility owner. Documents reviewed revealed that R1 had a history of skin breakdown and was treated by home health for wound care during various times while residing at the facility. The home health records reviewed dated 04/05/2022 through 05/27/2022, revealed that R1 was being treated twice per week for multiple pressure injuries. On various dates, the home health nurse documented R1’s pressure injuries as stage 1 and stage 2. During the visits to perform wound care, the nurse stressed the importance of continued pressure relieving measures and good nutrition and hygiene to promote healing, and when to seek medical attention if symptoms worsened. A review of the home health clinical notes for the month of May 2022 revealed that on 05/03/2022, the home health nurse performed wound care. Upon assessment of the wound, the nurse noted R1’s depends were soiled with urine. The nurse assisted with the caregiver to clean R1 and change R1’s depends. The caregiver assisted with repositioning R1 and the nurse stressed the importance of good nutrition, of increased protein, vitamin C and fluids to promote optimal wound healing as well as pressure relieving measures. Continued on 9099-C On 05/06/2022, the nurse documented that R1’s right buttock and coccyx wounds were now connecting making a larger wound, wound drainage is serous and moderate, no signs or symptoms of infection noted at that time. A wound consult was requested for concerns the wounds were slow to heal. The administrator informed the nurse that R1 was up all night talking and did not get much sleep. The nurse reviewed the plan of care with the administrator and stressed the importance of pressure relieving measures. On 05/10/2022, upon arrival for wound care, the nurse noted that R1 had soiled depends with urine and bowel movement. The nurse assisted the caregiver to clean R1 and change R1’s depends. The nurse noted the wound to right buttock and coccyx was not healing well, and may need a wound consult due to eschar and slough. The nurse sent a photo of the wound to the wound care specialist and received recommendations for conservative sharp debridement. The new wound care plans were reviewed with the caregiver and stressed the importance of repositioning at least every 2 hours and the importance of good hygiene. R1’s primary physician, Dr. Gonzales was also contacted to approve the wound care specialist orders. On 05/13/2022, the nurse noted wound to coccyx and right buttock not healing well, noted increase of moderate drainage to large serous drainage and noted odor to wound. R1 had increased pain. The nurse noted old wound to right hip had re-opened and photos were taken of wounds. The nurse reviewed the plan of care with the administrator and stressed the importance of pressure relieving measures and to seek urgent medical attention if worsening of symptoms or has life threatening symptoms. The home health nurse contacted Dr. Gonzales to report worsening of wound and possible concerns of infection and requested for a possible antibiotic. Dr. Gonzales was also notified of R1’s decline per the administrator, as R1 was not eating well, up all night, and sleeping during the day. On 05/17/2022, home health notes indicate R1’s sacrum/coccyx wound not healing, increased eschar to 90% and wound connected to right buttock wound, measured in one, all wounds measured, and photo taken. R1 was prescribed an antibiotic Cephalexin 500 mg one (1) tab four (4) times per day for seven (7) days. The nurse instructed caregiver in pressure relief in position changes, increase protein intake, adequate fluids and nutrition, keep depends dry and clean, and reviewed patient safety, caregiver verbalized understanding. Continued on 9099-C On 05/20/2022, the nurse documented that R1 received a supine position hospital bed. The administrator informed the nurse that R1 was eating very small meals over the last week, taking sips of fluids. The nurse noted the sacrum/coccyx wound not healing and connected to buttock wound, large amount eschar 90%. The nurse instructed the administrator to offer frequent fluids, protein, keep R1 frequently repositioned, clean and dry. On 05/24/2022, the home health nurse documented a visit to the facility for R1’s wound care and noted the pressure ulcer to R1’s sacrum/coccyx was a stage 2 and not healing. The wound measured at 10.5cm in length by 10cm in width by 0.4cm in depth. The wound tissue observed slough at 10% and eschar at 90%. The pressure injury to right buttock was a stage 2 healing by secondary intent also measured at 10.5cm in length by 10cm in width by 0.4cm in depth. The wound tissue observed slough at 10% and eschar at 90%. The pressure injury to R1’s left hip was a stage 2 healing by secondary intent. The wound measured at 4.5cm in length by 3cm in width by 0.1cm in depth. The wound tissue observed to be pink, beefy red. The nurse instructed the staff in infection control, signs and symptoms of infection, and when to call for immediate medical attention. On 05/27/2022, the home health nursing notes documented: “Management Aprilyn (administrator Soriano) refused the skilled nursing visit and stated they were now with a different home health agency and requested to be discharged from the agency”. On the same day, R1 was seen by a nurse practitioner and a physical exam was completed. The physician’s report dated 05/27/2022, listed R1’s diagnoses as congestive heart failure, aortic stenosis, atrial fibrillation, benign prostatic hyperplasia, anemia, and decubitus (pressure injury) stage 3-4 to buttocks. The report also lists conditions of dementia, blind, history of skin breakdown, functional quadriplegia, no capacity for self-care, and physical health status poor. The comments noted that R1 is bed bound and has not eaten in over 3 weeks, only liquids including Glucerna. R1 has just completed antibiotics for the decubitus (pressure injury). R1 appeared to be at end stage of life and a hospice referral was made. Facility progress notes document that on 05/27/2022, the administrator contacted R1’s resident representative to get approval for the hospice services. R1’s resident representative refused hospice services and insisted R1 be taken to the emergency room. Continued on 9099-C On 05/28/2022, R1 was admitted to the Marian Regional Medical Center. The hospital records indicated that in the emergency room, R1 was noted to have a large very malodorous ulceration in the sacral area which appeared to have deeper tunneling. “The patient is completely obtunded, tachycardic, hyponatremic. It appears the patient is not feeding self or participating in any activities of daily living. Patient is very ill at the time of presentation, septic and probably with a stage IV decubitus ulceration which was infected.” Based on records review and interviews, the Department has sufficient evidence to support the allegation “Facility retained a resident with a prohibited health condition”, therefore the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Nov 16, 2022 · control 29-AS-20220603151229

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Nov 17, 2022

87615(a)(1) Prohibited Health Conditions (a) Persons who ...have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when R1 (not on hospice) was diagnosed on 05/28/2022 with infected stage 4 pressure injuries, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee will submit a memo of understanding regarding Regulation 87615 Prohibited Health Conditions to CCL by 11/17/22

Allegation investigated: Staff neglected Resident #1 (R1) resulting in R1 developing stage 4 pressure injuries. Facility staff failed to seek medical attention in a timely manner for Resident #1 (R1) contributing to R1’s stage 4 pressure injuries.

Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver final findings for the above allegations. The initial complaint visit was conducted on 06/21/2022 by LPA Jeannette Olson. During today’s visit, LPA met with Administrator/Licensee and explained the reason for the visit. On 06/20/2022, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) developed a stage 4 sacral pressure injury while in care at the facility and the facility staff failed to seek medical attention in a timely manner for R1, contributing to R1’s stage 4 pressure injuries. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Heidy Bendana. On 06/21/2022, between 1:00pm and 2:30pm, LPA Olson conducted the initial 10-day complaint visit. The LPA met with Aprilyn Soriano, Administrator/Licensee, and explained the purpose of the visit. Continued on 9099-C Substantiated The LPA advised the Licensee that the complaint has been assigned to an Investigations Branch (IB) Investigator to conduct the investigation. The LPA requested documents pertinent to the investigation. Investigator Bendana conducted interviews on 07/28/2022 with residents, staff #1 (S1) and administrator; on 08/11/2022 and 08/12/2022 with Dignity Home Health Registered Nurse; on 08/12/2022 with R1’s Nurse Practitioner; on 09/02/2022 with R1’s Primary Care Physician; on 09/08/2022 with R1’s resident representatives; and on 09/09/2022 with Dignity Home Health Physical Therapist. Additionally, Investigator Bendana obtained and reviewed copies of R1’s Marian Regional Medical Center medical records, Dignity Home Health records, photographs of R1’s pressure injuries, death certificate, and facility records including documents relevant to R1. The investigation revealed that on 12/15/2020, R1 was admitted to the facility under the prior facility ownership. The facility had a change of ownership effective 01/12/2022, and the current licensee /administrator, Aprilyn Soriano became the new facility owner. Documents reviewed revealed that R1 had a history of skin breakdown and was treated by home health for wound care during various times while residing at the facility. The home health records dated 04/05/2022 through 05/27/2022, revealed that R1 was being treated twice per week for multiple pressure injuries. On various dates, the home health nurse documented R1’s pressure injuries as stage 1 and stage 2. During the visits to perform wound care, the nurse stressed the importance of continued pressure relieving measures and good nutrition and hygiene to promote healing, and when to seek medical attention if symptoms worsened. A review of the home health clinical notes for the month of May 2022 revealed that on 05/03/2022, the home health nurse performed wound care. Upon assessment of the wound, the nurse noted R1’s depends were soiled with urine. The nurse assisted with the caregiver to clean R1 and change R1’s depends. The caregiver assisted with repositioning R1 and the nurse stressed the importance of good nutrition, of increased protein, vitamin C and fluids to promote optimal wound healing as well as pressure relieving measures. Continued on 9099-C On 05/06/2022, the nurse documented that R1’s right buttock and coccyx wounds were now connecting making a larger wound, wound drainage is serous and moderate, no signs or symptoms of infection noted at that time. A wound consult was requested for concerns the wounds were slow to heal. The administrator informed the nurse that R1 was up all night talking and did not get much sleep. The nurse reviewed the plan of care with the administrator and stressed the importance of pressure relieving measures. On 05/10/2022, upon arrival for wound care, the nurse noted that R1 had soiled depends of urine and bowel movement. The nurse assisted the caregiver to clean R1 and change R1’s depends. The nurse noted the wound to right buttock and coccyx not healing well, may need a wound consult due to eschar and slough. The nurse sent a photo of the wound to the wound care specialist and received recommendations for conservative sharp debridement. The new wound care plans were reviewed with the caregiver and stressed the importance of repositioning at least every 2 hours and the importance of good hygiene. R1’s primary physician, Dr. Gonzales was also contacted to approve the wound care specialist orders. On 05/13/2022, the nurse noted wound to coccyx and right buttock not healing well, noted increase of moderate drainage to large serous drainage and noted odor to wound. R1 had increased pain. The nurse noted old wound to right hip had re-opened and photos were taken of wounds. The nurse reviewed the plan of care with the administrator and stressed the importance of pressure relieving measures and to seek urgent medical attention if worsening of symptoms or has life threatening symptoms. The home health nurse contacted Dr. Gonzales to report worsening of wound and possible concerns of infection and requested for a possible antibiotic. Dr. Gonzales was also notified of R1’s decline per the administrator, as R1 was not eating well, up all night, and sleeping during the day. On 05/17/2022, home health notes indicate R1’s sacrum/coccyx wound not healing, increased eschar to 90% and wound connected to right buttock wound, measured in one, all wounds measured, and photo taken. R1 was prescribed an antibiotic Cephalexin 500 mg one (1) tab four (4) times per day for seven (7) days. The nurse instructed caregiver in pressure relief in position changes, increase protein intake, adequate fluids and nutrition, keep depends dry and clean, and reviewed patient safety, caregiver verbalized understanding. Continued on 9099-C On 05/20/2022, the nurse documented that R1 received a supine position hospital bed. The administrator informed the nurse that R1 was eating very small meals over the last week, taking sips of fluids. The nurse noted the sacrum/coccyx wound not healing and connected to buttock wound, large amount eschar 90%. The nurse instructed the administrator to offer frequent fluids, protein, keep R1 frequently repositioned, clean and dry. On 05/24/2022, the home health nurse documented a visit to the facility for R1’s wound care and noted the pressure ulcer to R1’s sacrum/coccyx was a stage 2 and not healing. The wound measured at 10.5cm in length by 10cm in width by 0.4cm in depth. The wound tissue observed slough at 10% and eschar at 90%. The pressure injury to right buttock was a stage 2 healing by secondary intent also measured at 10.5cm in length by 10cm in width by 0.4cm in depth. The wound tissue observed slough at 10% and eschar at 90%. The pressure injury to R1’s left hip was a stage 2 healing by secondary intent. The wound measured at 4.5cm in length by 3cm in width by 0.1cm in depth. The wound tissue observed to be pink, beefy red. The nurse instructed the staff in infection control, signs and symptoms of infection, and when to call for immediate medical attention. On 05/27/2022, the home health nursing notes documented: “Management Aprilyn (administrator Soriano) refused the skilled nursing visit and stated they were now with a different home health agency and requested to be discharged from the agency”. On the same day, R1 was seen by a nurse practitioner and a physical exam was completed. The physician’s report dated 05/27/2022, listed R1’s diagnoses as congestive heart failure, aortic stenosis, atrial fibrillation, benign prostatic hyperplasia, anemia, and decubitus (pressure injury) stage 3-4 to buttocks. The report also lists conditions of dementia, blind, history of skin breakdown, functional quadriplegia, no capacity for self-care, and physical health status poor. The comments noted that R1 is bedbound and has not eaten in over 3 weeks, only liquids including Glucerna. R1 has just completed antibiotics for the decubitus (pressure injury). R1 appeared to be at end stage of life and a hospice referral was made. Facility progress notes document that on 05/27/2022, the administrator contacted R1’s resident representative to get approval for the hospice services. R1’s resident representative refused hospice services and insisted R1 be taken to the emergency room. Continued on 9099-C This is an amended report. On 05/28/2022, R1 was admitted to the Marian Regional Medical Center. The hospital records indicated that in the emergency room, R1 was noted to have a large very malodorous ulceration in the sacral area which appeared to have deeper tunneling. “The patient is completely obtunded, tachycardic, hyponatremic. It appears the patient is not feeding self or participating in any activities of daily living. Patient is very ill at the time of presentation, septic and probably with a stage IV decubitus ulceration which was infected.” After admission, R1 was treated aggressively with IV antibiotics and wound care. R1’s mental status did not improve, and R1 did not show signs of improvement. On 06/01/2022, R1’s resident representative opted to change the focus of R1’s care to comfort and R1 was transitioned to hospice care. By 06/03/2022, R1 was admitted to hospice and by 06/05/2022, R1 passed away. The Santa Barbara County Department of Health Certificate of Death lists the cause of death as Sepsis Proteus, Cellulitis, and Sacral Decubitus Ulcer. Information obtained through interviews found that the administrator and S1 both stated they were repositioning R1 every hour. However, it is unknown if this was happening as R1’s pressure injuries were progressively getting worse. A review of the facility repositioning logs, initialed by the administrator and staff, for the period of 05/01/2022 through 05/28/2022 at 11am, documented that R1 had been repositioned every hour. However, on a visit on 06/09/2022, LPA Olson reviewed R1’s entire file at the facility and observed repositioning logs for only 05/01/2022 through 05/10/2022 and obtained copies. Licensee later sent in the additional logs on 11/15/2022 that were not presented during the initial visit. Since the repositioning logs provided were only for May 2022, it is unknown if R1 was being repositioned every hour before or after that time period. The facility progress notes reviewed for the months of April and May 2022, initialed by the administrator, indicated that R1 was being repositioned every 2 hours. The interviews also revealed that a baby monitor was being used in R1’s bedroom. S1 stated she “checked” on R1 every 15 minutes. Administrator and S1 both stated they were aware that by May 1, 2022, R1’s wounds were getting worse and R1’s condition was declining. They noticed R1’s wounds getting bigger, noticed drainage, a bad smell and tunneling by 05/17/2022. R1 was complaining of increased pain and refusing to eat food, only drinking Glucerna. On the allegation: Staff neglected Resident #1 (R1) resulting in R1 developing stage 4 pressure injuries. The administrator and staff described how R1’s pressure injuries progressively worsened, R1 refused to eat, R1 complained of pain and R1’s condition worsened. Additionally, repositioning logs only show R1 was repositioned between 5/1/2022 and 5/24/2022, but there are no repositioning logs to show R1 was repositioned after 5/24/2022, and R1’s condition worsened. The administrator stated medical attention was pursued on 05/27/2022 only after R1’s resident representative requested it, and it was determined R1 had a septic Stage 4 pressure injury. Continued on 9099-C Based on record review and interviews the facility documented pressure injuries progressively worsening with the possibility of infection, yet no action was taken by the facility to seek medical attention, therefore the allegation is deemed Substantiated at this time. On the allegation: Facility staff failed to seek medical attention in a timely manner for Resident #1 (R1) contributing to R1’s stage 4 pressure injuries. The administrator had been instructed by the home health nurse on numerous visits to seek urgent medical attention if R1’s symptoms worsened. The administrator sought medical attention on 05/27/2022 only after R1’s resident representative requested it. Based on record review and interviews, the facility failed to seek medical attention in a timely manner when R1 started declining, when R1 refused to eat, and when R1’s pressure injuries progressively worsened, therefore the allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Administrator/Licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Nov 16, 2022 · control 29-AS-20220620111537

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 17, 2022

87468.2(a)(4) Personal Rights...residents ... shall have all of the following personal rights: 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 interviews and record review, the licensee did not comply with the section cited above when R1 was not given the proper care/supervision for worsening pressure injuries, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee will submit a plan how they will ensure all residents receive proper care and supervision to CCL by 11/17/22 An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Nov 17, 2022

87465(a)(1) Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the licensee did not seek medical attention in a timely manner when R1 started declining, refused to eat, and when R1's pressure injuries progressively worsened, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee will submit plan how you will ensure residents receive timely medical care. Submit to CCL by 11/17/22

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-20220620111537). LPA met with Administrator/Licensee and explained the purpose of the visit is to issue citations for deficiencies observed during the complaint investigation. During the complaint investigation of Complaint #29-AS-20220620111537, the following deficiencies were observed: The licensee did not inform R1’s resident representative when R1 had a change of condition. R1’s pressure injuries worsened, R1 refused to eat, lost weight, complained of pain, and had a significant decline in health condition. The Administrator/Licensee did not demonstrate they have knowledge of the requirements for providing care and supervision appropriate to the residents, as Licensee retained R1 with prohibited health conditions. R1 was bedridden and depended on others to perform all activities of daily living for them and R1’s pressure injury worsened to stage 4. The LIC 500 Personnel Report, dated 01/13/2022, lists the administrator’s schedule as Monday through Saturday 7:00am to 9:00pm. It does not list the administrator as a caregiver. The “hourly rounding and routine care logs”, dated 05/01/2022 through 05/24/2022 are initialed by the administrator every hour from 6:00am to 9:00pm, on Monday, 05/01/2022 through Thursday, 05/05/2022 and Saturday, 05/07/2022 and Tuesday, 05/10/2022, which indicates they were a caregiver and not performing administrator duties on those dates and times. The LIC 500 shows one caregiver for each shift except for Sunday does not show any caregiver coverage from 6:00pm to 9:00pm. Continued on 809-C The facility used a baby monitor in R1’s bedroom to monitor R1. The Medication Assistance Record (MAR) for the date of 05/26/2022, is initialed by staff as all medications given. The facility progress notes on 05/26/2022 state “R1 refused all medications due to pain”. The Appraisal Needs and Services Plan, dated 01/13/2022, is missing information on page one (1), has not been updated with R1’s change of condition, and is not signed or dated by R1’s resident representative. The Register of Residents form, dated 05/09/2022, did not list the required information regarding R1. R1’s name, ambulatory status, information on R1’s physician and resident representative information were missing. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Nov 16, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Nov 17, 2022

87466 Observation of the Resident:The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidenced by:the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee will submit plan how the facility will ensure residents are regularly observed for changes in condition, and that they will document it and notify the resident’s physician and resident’s representative when changes are observed. Submit plan to CCL by 11/17/22. Based on record review and interviews, the licensee did not comply with the section cited above in not informing R1’s Medical POA of the multiple changes including a significant decline in health, which posed an immediate health and safety risk to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(1) · Plan of correction due date: Nov 17, 2022

87405(d)(1) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met evidenced by: Based on records review, the licensee did not comply with the section cited above as R1 was retained with prohibited conditions, was bedridden and depended on others to perform all daily living activities, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee will read and review regulation 87405 and 87615 Prohibited Health Conditions and submit plan how you will ensure the residents are provided appropriate care and supervision at all times. Submit to CCL by 11/17/22

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 17, 2022

87411(a) Personnel Requirements - General: (a) 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 records review, the licensee did not comply with the section cited above. The LIC500 Personnel Report did not reflect staff coverage on Sundays from 6:00pm to 9:00pm and did not list accurate hours for the administrator, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee will submit a current, complete, accurate LIC 500 Personnel Report showing sufficient staffing 24/7. Submit to CCL by 11/17/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Nov 23, 2022

87468.2(a)(1)..PersonalRights...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations medical treatment, personal care and assistance, visits, communications... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the facility used a baby monitor in R1’s bedroom to monitor R1, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee will submit memo of understanding that the facility will not use baby monitors in the residents’ rooms. Submit to CCL by 11/23/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(3) · Plan of correction due date: Nov 23, 2022

87405(d)(3) Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications...in Sections 87405(d)(1) through (7)... (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when Medication Assistance Record on 05/26/2022 is initialed all medications given, yet facility progress notes state on 05/26/2022 “R1 refused all medications due to pain”, which posed a potentail risk tothe state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee will submit plan how you will ensure accurate recordkeeping of residents’ medication administration. Submit to CCL by 11/23/22. residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(3) · Plan of correction due date: Nov 23, 2022

87463(a)(3) Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate…Significant changes shall include but not be limited to (3)... change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above by not updating the appraisal with R1's changethe state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee will submit plan how the facility will ensure resident appraisals will be updated as needed to ensure appraisal is accurate. Submit to CCL by 11/23/22 of condition, is not complete with background information, and is not signed or dated by R1’s resident representative, which posed a potential health and safety risk to residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87508(a)(1)(2)(3) · Plan of correction due date: Nov 23, 2022

87508(a)(1)(2)(3) Register of Residents : The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: (1) The resident's name and ambulatory status (2) Information on the resident's attending physican...(3) Informaion on the resident's responsible person… This requirement is not met as evidenced by:Based on records review, the licensee did not comply with the section cited above when the Register of Residents form, dated 05/09/2022, did not list the required information regarding R1, which posed athe state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee will submit a copy of a current and complete Register of Residents to CCL by 11/23/22. potential health and safety risk to residents in care.

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 11/16/2022 2:45 PM. LPA met with Administrator/Licensee and explained the purpose of the visit. LPA took a physical plant tour of the facility with Administrator. The facility has not submitted an Infection Control Plan to the department, Technical Assistance was issued. 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 as needed. 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 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/Licensee 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 cabinet. 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. The facility has working smoke and carbon monoxide detectors present in the facility. At Approximately 2:50 PM LPA observed 2 staff in the facility to not be wearing masks. At Approximately 3:05 PM LPA observed 2 fire extinguishers charged but last inspected on 09/09/2021 At approximately 4 pm, LPA reviewed 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. LPA observed 2 staff working were not on the Staff roster and Administrator stated they had a lot of turn over and is hard to keep updated. Staff were fingerprint cleared and associated. Administrator will submit a updated LIC 500 to CCL. Pursuant to Title 22 Division 6 Chapter 1 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview completed, copy of report and appeal rights were emailed and mailed to Administrator/ Licensee.the state’s words, verbatim · CDSS document, Nov 16, 2022

Type of visit: Prelicensing

Licensing Program Analysts (LPA) Diaz conducted a pre-licensing visit to the facility above at 8:39am. LPA met with Applicant Aprilyn Soriano and Consultant, Debra Ermac and Administrator Cheryll Ate. The applicant has obtained fire clearance for (6) non-ambulatory and (4) bedridden residents, for a total capacity of six (6) Residents. Beginning at 9:07am, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired smoke alarms were functioning properly at this time. 1 out of 2 carbon monoxide detectors was not functioning. LPA observed one fire extinguisher to be fully charged and newly purchased. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. A working telephone is present. The facility has a comfortable temperature of 74 degrees. The proposed facility has 4 resident bedrooms total. There are 2 single-occupancy bedrooms and 2 double occupancy bedroom designated for resident use. The 3 resident bedrooms were furnished and contained beds, chairs, bedside tables and lamps. All beds have sheets, pillows, and mattress pads. 1 double occupancy room is missing a bedroom dresser and closet door hinge is broken. There is also an ample supply of linen, towels and paper products. The proposed facility has (2) full bathrooms for resident use. LPA observed a night-light present in the main hallway. Hot water measured at 113.2 degrees Fahrenheit at approx. 9:50am The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of water. A locked medication cabinet and First aid kit was observed to be complete. There is space to lock Chemicals in the garage and under the kitchen sink and in the laundry room. Sharp items are stored in a locked kitchen drawer. The laundry room is located next to the kitchen and supplies will be stored in the locked garage cabinets. The building and grounds are free from hazard. LPA and Applicant Aprilyn Soriano completed component III The following needs to be completed/proof submitted prior to the facility being licensed: 1. Provide Dresser in bedroom 1. 2. Provide a functioning Carbon Monoxide detector 3. Complaint poster needs to be size 20 by 26 color 4. Repair closet door hinge This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Dec 28, 2021

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): YES (6) Method: Telephone call with CAB COMP II Participants: Aprilyn Soriano Applicant/administrator Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1.Facility operation: License type, client/resident populations, and program 2.Staff qualifications and responsibilities 3.Applicant and Administrator qualifications 4.Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5.Grievances, Complaints, Community resources 6.Physical plant, food service 7.Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property 8. Discussed the COVID-19 Mitigation Plan & PIN emailedthe state’s words, verbatim · CDSS document, Dec 21, 2021