Townsend House

Allegation investigated: Staff did not supervise resident while outside in extreme temperatures

On September 18, 2023, LPA's Boyles and Avila arrived to the facility unannouced for a complaint investigation visit. On August 15, 2023, R1 was found unresponsive outside on the patio by another resident family member at approximately 4:11 PM. Per interviews with staff, R1 was taken outside after lunch by the receptionist who did not tell relay this information to other facility staff. R1 had been sitting outside for approximately 2 hours and 45 minutes, or longer when temperatures were increasing and reached 108 degrees (F) by 2:00 p.m. The temperatures were verified by a local city weather graph (timeanddate.com). When R1 arrived at the hospital their body temperature was 106.1 degrees (F). Based on LPAs interviews which were conducted and record reviews, the preponderance of evidence standard has been met; therefore, the above allegation are found to be SUBSTANTIATED. California Code of Regulations Title 22 and or the California Health and Safety Code are being cited on the attached LIC 9099D. Appeal rights left with Adminstrator. Substantiatedthe state’s words, verbatim · CDSS document, Sep 18, 2023 · control 59-AS-20230816163819

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 18, 2023

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs or the physical arrangements of the facility require such additional staff for the provision of adequate services. The requirement is not met as evidence by: Based on observation, interviews and record review, the licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period of time in extreme heat, which poses an immediate Health, Safety, Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 18, 2023

Plan of correction: Staff are checking for all clients within the wing assigned. Training for heat stroke/illness was adminstered for all staff. Staff are setting timers for residents when outside, and bringing the resident back inside.

Allegation investigated: Resident's facility fees were increased without proper notice

LPA Hiratsuka, conducted this visit to deliver the results of the investigation above. LPA Hiratsuka investigated the allegation “Resident's facility fees were increased without proper notice.” LPA interviewed Administrator about the rate increase. The resident in question had a change in condition. The administrator had several meetings with the resident's responsible parties and did the rate increase. CA Health and Safety Code Resident's facility fees were increased without proper notice. For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. Substantiated 2. LPA interviewed resident and a couple of staff. Resident stated there's no issue with care but the catheter has leaked a couple of times and came apart a couple of times. Staff stated resident wears a catheter and has a habit of disconnecting it. LPA cannot determine if the staff are not monitoring the resident enough to prevent the catheter issues. 3. The resident has a wheelchair and the complainant stated there have been several times that things were put on the wheelchair preventing the resident from using it. LPA interviewed resident and the resident stated they have had no issues with the chair not being available. Staff stated that things have been found on the chair and the resident has told them to put things on there as well. LPA cannot prove or disprove the issue because each side has their own version of events. Due to the information gathered, LPA cannot determine the allegations 1. Staff did not seek timely medical care for resident in care; 2. Staff did not provide proper incontinence care to resident in care; 3. Resident's mobility device are not readily accessible to resident in care.. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. The administrator did not do the correct way to increase the rate due to level of care. She had the meetings but did not follow up the increase properly in writing. Based on the above, the allegation is substantiated. Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left 5. LPA interviewed the resident in question. Resident stated they refuse to take a shower on their own. The resident does get one when requested. The resident also stated there has been no issue of staff leaving theme alone while being bathed. Based on the interview the allegation is unfounded. 6. LPA interviewed the resident. Resident stated the pendant is always worn except when they chose to have it put on a table or somewhere else. Resident stated they have no issues getting assistance when requested. Based on the interview the allegation is unfounded. “This agency has investigated the complaint alleging; 4. Staff are not providing proper medication assistance to resident in care; 5. Staff did not provide proper shower assistance to resident in care; 6. Resident in care did not have access to his pendant. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis."the state’s words, verbatim · CDSS document, Jul 12, 2023 · control 59-AS-20230313141308

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Aug 11, 2023

Rate increase due to change in level of resident care; notice. For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional .services to be provided at the new level of care and an accompanying itemization of the charges. cont. belowthe state’s words, verbatim · CDSS document, Jul 12, 2023

Plan of correction: By 08/11/2023, the licensee shall submit in writing how they shall ensure all rate increases due to level of care are implemented correctly.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Jul 12, 2023

not a new citation. Continued from above. This requirement is not met as evidenced by: Based on LPA's interview the increase was not done correctly. This does not pose an immediate risk to residentsthe state’s words, verbatim · CDSS document, Jul 12, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit utilizing the infection control domain. LPA met with administrative assistant and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA Wallace and administrative assistant assistant toured facility together to ensure health and safety of clients who attend the day program. Areas toured include but are not limited to: common areas, bathrooms, office, and storage rooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Wallace and Administrator Assistant completed the infection control domain and facility was found to be in substantial compliance at this time. Hot water temperature was measured at 113.4 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers were last inspected on 10/10/2022. Smoke and carbon monoxide sensors are in compliance with fire safety. Thermostat observed at (74.5) degrees Fahrenheit. LPA reviewed four (4) client records and four (4) staff records. All documents were complete and staff have current first aid certificates. No deficiencies are being cited as a result of today's inspection. Exit interview conducted and copy of report was provided to administrative assistant at facility.the state’s words, verbatim · CDSS document, Feb 9, 2023

Allegation investigated: Staff did not ensure that a visitor followed the Covid 19 mask guidance.

Donna Gurriere, Licensing Program Analyst was in contact and met with Chablis Pasquale, Administrator. It was alleged that Staff did not ensure that a visitor followed the Covid 19 mask guidance. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. **continued** Unsubstantiated **continued** Staff did not ensure that a visitor followed the Covid 19 mask guidance. During the interview process, the administrator, five staff persons and three residents were interviewed. None of the staff persons or residents indicated that there was a visitor that did not follow the Covid 19 mask guidance. In addition, all staff persons stated that they are prepared to speak out and ensure that all visitors follow the Covid 19 mask guidance when at the facility. Overall, it could not be proven that a visitor did not follow the Covid 19 mask guidance. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. No deficiencies cited.the state’s words, verbatim · CDSS document, Jan 31, 2022 · control 25-AS-20210825134854

Allegation investigated: Staff left resident unattended during toileting. Staff were not sufficient in numbers to provide services to meet the resident's need for telephone calls.

Donna Gurriere, Licensing Program Analyst was in contact and met with Chablis Pasquale, Administrator. It was alleged that Staff left resident unattended during toileting and Staff were not sufficient in numbers to provide services to meet the resident’s need for telephone calls. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. continued Unsubstantiated Staff left resident unattended during toileting. During the interview process, the administrator and five staff persons were interviewed. In addition, the resident’s Physician Report, medications log, resident’s care plan and staff and resident rosters were reviewed. It was reported by the administrator and staff that they were not aware that a resident was left unattended during the toileting time. Staff advised that the resident needs standby assistance or that the resident will use the call button to summon staff to assist in toileting. None of the staff were aware that the resident was left unattended. There is not enough evidence to support that the resident was left unattended while toileting. Allegation is Unsubstantiated. Staff were not sufficient in numbers to provide services to meet the resident’s need for telephone calls. During the interview process, the administrator and five staff persons were interviewed. In addition, the resident’s Physician Report, medications log, resident’s care plan and staff and resident rosters were reviewed. During the interview process, the administrator and five staff reported that staff are sufficient in numbers and that they for the most part are available to answer telephone calls. During the work week, there generally is a receptionist available from 8:00 a.m. to 4:30 p.m. It was reported that on a few occasions, a telephone call may have been missed as the staff were providing care to the residents or were assisting the residents to the dining room. It was stated that some residents have their own telephones in their rooms, some of the residents have chosen not to have a phone in their room and are required to rely on staffing. Although there may have been times where a telephone call was missed, overall staff reported that there is sufficient staffing. There is not enough evidence to support that there is insufficient staffing for staff to answer telephone calls. Allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Dec 14, 2021 · control 25-AS-20210817082706

Type of visit: Required - 1 Year

12/13/2021 10:45 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator Chablis Pasquale and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask, gloves. Additionally, LPA Knight was screened by Chablis Pasquale, administrator. LPA Knight and Ms. Pasquale toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathrooms, office, activity room, staff screening station, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight and the administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Technical assistance was provided. Exit interview conducted and copy of report was emailed to administrator Chablis Pasquale.the state’s words, verbatim · CDSS document, Dec 13, 2021

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.