Sandy's Residential Care Home

Allegation investigated: Staff are using locks as restraints for the residents while in care

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of this complaint investigation. LPA met with Licensee, Azucena “Sandy” Zipagan. On 03/29/2023, the Department received a complaint alleging staff are using locks as restraints for the residents. It was alleged that the resident’s bedroom doors had the ability to be key locked from the outside of the room and the residents does not have capability to unlock the door from the inside. It was also alleged that staff lock the residents’ doors at night to let staff sleep. On 04/05/2023, the initial complaint investigation was conducted. During the initial investigation, LPA Dolores observed all the resident bedroom doorknobs. Based on observation, all the resident bedrooms contained a “panic proof” doorknob with the ability to be locked from the inside. The door can be easily unlocked by turning the doorknob from the inside of the bedroom. The outer part of the doorknob facing the common area requires a key. Facility staff have a key to each bedroom. SEE LIC9099-C. Unsubstantiated Based on interview with the Licensee, the panic proof doorknobs were implemented about two weeks ago from 04/05/2023. A different set of doorknobs were installed after the HCBS final rule was implemented, which was observed by another State agency. The set of doorknobs observed by another State agency were not a “panic lock” and required the residents to unlock the door by turning the button from the inside. The staff had a key to each bedroom. Licensee states there are / were no residents being locked in their bedrooms during the night. The facility does not have a resident who has wandering behaviors. Based on interview with the staff (S2), the facility does not have a resident with wandering behavior during any time of the day. S2 states none of the residents are being locked in their bedrooms but the residents can lock their doors for privacy if they want. S2 states the staff has a key to each bedroom in case of an emergency. The facility has live-in staff on premises and the residents know where the staff resides in case they need anything during the night. Residents are also being checked on during the nighttime. Based on resident interviews, R2 states to have never been locked out of his/her room or locked in his/her room. R1 was able to communicate with LPA but was unable to answer the questions asked. Two residents (R1 – R2) successfully demonstrated how to unlock their bedroom door. The review of resident records shows that R1 – R3 does not have wandering behavior and are able to follow instructions. Correspondence shows the facility was in contact with another State agency regarding guidance on the implementation of locked doorknobs in the resident’s bedrooms. The facility was asked to place the lock doorknobs back to be in HCBS compliance. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee, Azucena “Sandy” Zipagan and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 26-AS-20230329161259

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Licensee, Sandy Zipagan. During visit, LPA toured the facility to include the kitchen, living room, residents rooms, bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. Facility temperature maintained at 78 degrees Fahrenheit. Facility has a designated entry point for visitor sign in, symptom screening, and temperature check. Hand sanitizer available at entry. Bathrooms supplied with hand washing sign, and paper products. Facility staff clean and disinfect multiple times daily and as needed. LPA observed the facility's Personal Protective Equipment (PPE) supplies. LPA reviewed facility's procedures to isolation, visitation, and infection control training. Staff are not N95 fit tested. The following posters observed to include cover your cough, feeling ill, keeping the facility clean, symptoms of COVID, and hand washing sign. LPA advised to remove PIN 21-40-ASC posted at the front door and inside the facility. LPA advised to reviewed PIN 22-28-ASC regarding the latest information on visitation. No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Sandy Zipagan and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 3, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Azucena Zipagan. During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed a visitor screening area at the facility entrance. LPA Marrufo observed COVID-19 related signs and posters posted throughout the facility hallways. LPA Marrufo toured two out of two bathrooms and observed there to be available soap and paper towels as well as hand washing guidance posters. LPA Marrufo observed there to be a PPE supply of at least 30-days. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Azucena Zipagan and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 14, 2021