Veterans Home of California-Redding

Allegation investigated: Insufficient staff to meet resident needs

On 10/04/2023 Licensing Program Analysts (LPAs) Ivan Avila and Jaynae Boyles conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPA Avila met with Pamela Eiszele and explained the purpose of the visit. During the interview process, five staff members and three residents were interviewed. In addition, a staff and resident roster list were reviewed, and a call log history was also reviewed. During the interview process, it was stated that residents have three call buttons in their rooms. Once a resident presses their call button for help, staff respond within a couple of minutes. Resident interviews stated that staff are meeting their needs and there is sufficient staff at the facility but could be better. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 4, 2023 · control 59-AS-20230725151536

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 09/26/2023 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with Pamela Eiszele and explained the purpose of the visit. LPA Avila and Administrator toured facility together to ensure the health and safety of residents in care. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in a locked area. Water temperature measured at 117 degrees. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident bathrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene products. Common Areas: These included but at not limited to the living area, activity area, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. Record Review: Facility records are stored inaccessible to residents. The LPA reviewed five (5) staff, and five (5) resident files. All documents reviewed appeared complete and current. Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to residents in care; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record log. No errors observed during the medication review. Exit interview conducted and copy of the report was provided to Pamela Eiszele.the state’s words, verbatim · CDSS document, Sep 26, 2023

Allegation investigated: The administrator does not treat the residents with dignity and respect.

Donna Gurriere, Licensing Program Analyst was in contact and met with Pamela Eiszele, Administrator. Allegation is that the administrator does not treat the residents with dignity and respect. 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: Surgical mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. continued Unsubstantiated The administrator does not treat the residents with dignity and respect. During the investigative process, the administrator, five staff persons and four residents were interviewed. During the interview process several persons indicated that they were surprised that there was an allegation of the sort. Staff persons and residents stated that they have not had a problem with the administrator, that they felt that she does her best and that they do believe that the administrator treats the residents with dignity and respect. Overall, it was reported that the administrator does show dignity and respect to the residents. 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.the state’s words, verbatim · CDSS document, Feb 6, 2023 · control 25-AS-20230111150136

Allegation investigated: Facility stopped delivering packages to residents.

Donna Gurriere, Licensing Program Analyst was in contact and met with , Pamela Eiszele, Administrator. Allegation is in regard to Facility stopped delivering packages to residents. 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: Surgical mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. continued Substantiated During the investigation documents were obtained. A letter was sent to the residents that read “Effective Wednesday September 14, 2022, packages will no longer be delivered to you. Staff will have packages available for you to pick up at the Hall of Honors. The time will be 1530-1600 Monday through Friday. If you are not available to pick up, the package will be available the following day at the same time. This will exclude any holidays that may fall during the week. We are attempting to streamline processes. This will allow staff to gather all deliveries received. If you should have any questions, please see staff. Thank you for your kind consideration in this matter.” The letter was signed by the administrator. A concern was raised in that there could be some residents that were nonambulatory that could not carry their packages if they were using a walker or a wheelchair. The directive was in place from 09/14/22 through 10/18/22. The administrator advised that those residents that were nonambulatory would have assistance from the care providers in getting their packages; however, that was not stated in the initial letter. Regulations state in part that residents are to receive unopened correspondence in a prompt manner. Residents were advised that they would be responsible to collect their own packages and therefore may not have received their packages in a prompt manner. Based on LPAs review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted.the state’s words, verbatim · CDSS document, Jan 17, 2023 · control 25-AS-20221004151723

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(15) · Plan of correction due date: Jan 18, 2023

Personal Rights of Residents in All Facilities - To send and receive unopened correspondence in a prompt manner. The licensee did not ensure that this requirement was met as evidenced by a letter that was provided to the residents indicating that they would be responsible to obtain their own packages.the state’s words, verbatim · CDSS document, Jan 17, 2023

Plan of correction: On 10/18/22, the administrator changed the policy in that packages were delivered to the residents’ rooms by the care providers. No further plan of correction is required.

Allegation investigated: Resident requested sun blocking film or shades for their window and the facility has not installed it in resident's room.

/07/2022 Licensing Program Analyst (LPA) Shannon Diegoruelas, made an unannounced visit to the facility and met with Pamela Eiszele, Administrator for the facility. The purpose of this visit was to deliver the results of the complaint investigation of the above allegations. Prior to initiating the visit, LPA completed required daily self-screening for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by security. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Interview with resident (R1) indicated that they spoke with facility management on multiple occasions requesting sun blocking film or shades be place in their bedroom window and believe they were ignored. Interview with the Administrator indicated that they were not aware of any request being made by R1 for sun blocking film or shades. The facility did not have any work orders prior to the complaint to provide to LPA indicating that a request had been made by R1. The facility opened a work order on 6/16/2022 to tint the windows in R1’s room. As of to date, the facility provided documentation to LPA indicating that the work order was completed on 6/21/2022. Based on interviews conducted, LPA finds the allegation to be UNSUBSTANTIATED, a finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited during today's visit. Exit interview was conducted and a copy of the report was provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 7, 2022 · control 25-AS-20220606112531

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1- Year Annual Inspection Visit and met with. Prior to initiating the visit, 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: surgical mask and gloves. Additionally, LPA was screened by front desk security. LPA Wallace and administrator toured the facility inside and out including but not limited to facility front entrance, living room, resident bathrooms, kitchen area, outside area, outside resident bedrooms, storage rooms, and medication room. All passageways are free of obstruction. LPA observed the smoke/monoxide alarms to be in working order and the fire extinguishers are fully charged which expire 1/24/2023. Facility is conducting quarterly fire drills and the last one was conducted 8/16/2022. The hot water measured 106.3*F which is within the required range of 105-120*F. All staff were observed to be wearing surgical masks. Facility entrance is equipped with proper COVID-19 signage and screening station. Facility has a mitigation plan in place should a COVID positive case occur. Facility has sufficient supply of perishable food, non-perishable food, medication, and PPE. LPA reviewed 6 of 81 resident records and LPA reviewed medications of 2 residents comparing with Centrally Stored Medication Record and physician orders. LPA reviewed 4 staff records and all have health screen and TB results. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed all have current first aid certificates. LPA Wallace completed infection control domain and observed no issues or concerns. No deficiencies cited today from California Code of regulations, Title 22. Exit interview conducted with administrator and a copy of report was provided.the state’s words, verbatim · CDSS document, Sep 13, 2022

Allegation investigated: Facility put substance in resident's beverage

***AMENDED*** This report is being amended from confidential to public. This is the only change to the report. Licensing Program Analyst's (LPA's) Shannon Diegoruelas and Misty Valencia conducted an unannounced complaint visit and met with Pamela Eiszele, Administrator to deliver investigation findings. Prior to initiating the visit, LPA's 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's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical masks. Additionally, LPA's was screened by staff at the front door. Continued on 9099C Unfounded The Department finds from interviewing the psychologist and his records review dated 10/25/21, 11/10/21, and 02/10/22 that R1 is diagnosed with: *Severe personality disorder *Borderline personality disorder traits *Maladaptive personality traits *Paranoia psychosis *Delusional ideation/thoughts It was reported by the psychologist that R1 was having a paranoia episode, believing someone put something in his water. It was determined through other interviews with Administrator, staff, and residents that eight of eight (8 of 8) staff and four of five (4 of 5) residents reported they have never heard of or witnessed any issues regarding substances being put into resident's beverages. LPA finds allegation to be without merit or cause. As a result of this investigation, LPA finds allegation to be (U) Unfounded - A finding that the complaint is Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and copied of report was emailed to Administratorthe state’s words, verbatim · CDSS document, Mar 30, 2022 · control 25-AS-20220208083000

Type of visit: Office

On Febuary 7, 2022, a Non-Compliance Conference was conducted on this day in the Sacramento North Regional Office via Webex, due to COVID 19 precautions. The purpose of this Non-Compliance Conference meeting was to discuss the citations that were issued on 1/20/2022 regarding a COVID-19 outbreak at the facility. Present in the meeting was licensing Program Manager (LPM) Laura Munoz in lieu of Regional Manager (RM) Alycia Berryman, LPM Troy Ordonez, LPA Misty Valencia, and LPA Shannon Diegoruelas, Lori Templeton, Administrator,Pam Eiszele, Administrator,Ron Thoreson, AHH,Rebecca Alexander , Administrator Assistant,Dixie Pridmor, Infection Control officer, Kristi Munson, Quality Assurance,Beth Muszynski, Asst Deputy Secretary,Dan Maullam, Chief Counsel,Tina Ramirez, Human Resources Director and Manny Dumangas, Infection Control officer. The Non-Compliance Conference process was explained during this meeting to include the Covid 19 staff protocols. Issues discussed during the meeting were : -On 12/17/2021, the Sacramento North Regional Office received a report of a new COVID-19 positive staff person via email. -Infection control: facility staff working with symptoms -Not adhering to the Public Health Order (testing visitors, record keeping) -COVID-19 staff screening - clarification regarding following the strictest guidance continued on 809-C The facility has stated they will do the following to achieve continued and substantial compliance: The Department would like the facility to submit the following by: 2/14/22 · A plan on how facility staff will be trained in required areas prior to completing duties: · Plan should include - responsibility will be to conduct training, monitor training and document training. · The Department may increase monitoring at your facility. · Facility will comply with strictest guidance related to COVID-19 · Facility will report all COVID-19 positives within 24 hours by phone or fax, or email. · Facility will provide updated mitigation plan · Submit a Personel Report LIC 500 · Facility will updated staff screening documents that shows no symptoms within forty-eight (48) hours and not four(4) hours Licensee agrees to complete required training for all care staff. The Licensee shall send a list detailing the date and topic of training. · A progress report compliance meeting may be conducted at the end of the six month time period outlined by the Non-Compliance Conference. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted and a copy of this report was provided via email.the state’s words, verbatim · CDSS document, Feb 7, 2022

Type of visit: Case Management - Legal/Non-compliance

On 01/03/2022, Jaclyn Avila, Licensing Program Analyst (LPA) conducted a case management visit to the facility for the purpose of delivering an Order to Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion from Facility. Prior to initiating the visit, 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: PAPR. LPA completed the facility screening questionnaire. LPA Avila met with the Administrator Pam Eiszele, Assisted Administrator Ron Thoreson, Kristi Mudson Standards Compliance Coordinator and explained the purpose of today's visit. Angela Metropulos, Staff Person is excluded as of this date 12/31/2021, due to her actions related to this facility. LPA Avila handed the Order to Licensee/Facility of Immediate Exclusion from the Facility and explained that staff person Angela Metropulos cannot be allowed to work, be present and/or live in a Community Care Licensing (CCL) licensed facility or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Prior to arriving at the facility, LPA Avila attempted to meet with Angela Metropulos but was unable to make contact to serve the Order to Individual of Immediate Exclusion from all facilities. A copy of this report was provided to the Administrator via e-mail.the state’s words, verbatim · CDSS document, Jan 3, 2022

Type of visit: Required - 1 Year

On 9/28/21 at 11:30 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced required 1-year annual inspection and met with Standard Compliance Coordinator Kristi Munsun. Prior to initiating the visit, 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; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Additionally, LPA was screened by front desk security. LPA Cheng toured the facility inside and out including but not limited to facility front entrance, living room, resident bathrooms, kitchen area, outside area, outside resident bedrooms, storage rooms, and medication room. All passageways are free of obstruction. All staff were observed to be wearing surgical masks. Facility entrance is equipped with proper COVID-19 signage and screening station. Facility has a mitigation plan in place should a COVID positive case occur. Facility has sufficient supply of perishable food, non-perishable food, medication, and PPE. LPA Cheng completed infection control domain and observed no issues or concerns. No deficiencies observed. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Sep 28, 2021

Type of visit: Case Management - Other

Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit. LPA Gurriere met with Pamela Eiszele, Administrator and advised of the purpose of the inspection. 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 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 was screened by the receptionist upon entering the facility. During the month of June 2021, it was reported that a resident’s (Resident 1) medications were not accurate. The purpose of this visit is to review a resident’s medications and ensure that the facility is following the physician’s medication orders for the resident. The resident was interviewed and advised that in March 2021 his physician lowered a dosage amount of a medication that he was taking. The resident has requested that the administrator talk to his physician to see if the medication can be increased to assist with a side effect that he is experiencing. The administrator has agreed to speak with the resident's physician to ask if the physician can re-review the resident's medication. The facility staff are currently following the physician's orders of the prescribed medication. During today's visit the administrator scheduled a visit for the resident to see his physician. An exit interview was conducted, and a copy of the report was given to the administrator.the state’s words, verbatim · CDSS document, Jul 7, 2021