Hallmark House

Type of visit: Required - 1 Year

On 07/26/ 2023, Licensing Program Analysts (LPA's) Jaynae Boyles and Kerry Hiratsuka arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA's met with Facility Manager Laura Dale explained the purpose of the visit. LPA's Boyles, Hiratsuka and manager toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms. LPA's observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 110 F. LPA's observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA's reviewed a total of four (4) residents' files and two (2) staff files. In the areas toured no immediate health, safety, or personal rights violations were observed. Several topics were discussed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jul 26, 2023

Type of visit: Required - 1 Year

On 05/04/2022 Licensing Program Analysts (LPAs) Misty Valencia and Dawn Keane, arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with Audra Eneix, Administrator and explained the purpose of the visit. 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 Facility Administrator Melissa Johnson 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, LPAs were screened at the front entrace. LPAs and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms.. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and 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. Exit interview conducted and copy of report emailed to Administrator.the state’s words, verbatim · CDSS document, May 4, 2022

Allegation investigated: Personal Rights- cameras with audio in the facility

On 12/15//2021, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit to deliver findings regarding the above allegations directed by the department. LPA met with Maria Teibel, Direct Care Staff and explained the reason for the visit. 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 masks. Additionally, LPA was screened by staff at the front door. continued on 9099-C Unsubstantiated During interviews with Administrator, staff, resident and records reviewed, it was determined; Cameras with audio in the facility to be unsubstantiated. LPA toured the facility, and during the visit, LPA interviewed Six of Six (6 of 6) staff, who reported they have never had any issues or concerns regarding cameras with audio in the facility. 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. There were no citations issued during today's visit, copy of report was given. An exit interview was conductedthe state’s words, verbatim · CDSS document, Dec 16, 2021 · control 25-AS-20211004124709

Allegation investigated: Resident is being over medicated Resident falls Due to overmedicated Resident appears to have long/dirty fingernails

On 12/15//2021, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit to deliver findings regarding the above allegations directed by the department. LPA met with Maria Teibel, Direct Care Staff and explained the reason for the visit. 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 masks. Additionally, LPA was screened by staff at the front door. continued on 9099-C Unsubstantiated Resident is being over medicated Resident falls Due to over-medicated Resident appears to have long/dirty fingernails During interviews with Administrator, staff, residents, and records reviewed, it was determined; Resident is being over medicated, Resident falls Due to over-medicated, and Resident appears to have long/dirty fingernails to be unsubstantiated. LPA toured the facility, and during the visit, LPA interviewed Five of Five (5 of 5) residents, which all reported they have no concerns regarding medications or personal care. LPA interviewed Five of Five (5 of 5) staff, who reported they have never witnessed or heard anything regarding any Resident is being over medicated, Resident falls Due to over-medicated, or any residents having long/dirty fingernails. While reviewing records, LPA observed some medication errors (missed medications), but not any residents being over medicated. LPA will conduct a case management regarding medication errors. LPA finds the allegations 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. There were no citations issued during today's visit, copy of report was given. An exit interview was conductedthe state’s words, verbatim · CDSS document, Dec 16, 2021 · control 25-AS-20211008112012

Type of visit: Case Management - Deficiencies

On 12/16//2021, Licensing Program Analyst (LPA) Misty Valencia conducted an announced case management investigation visit regarding medication errors. LPA met with Maria Teibel, Direct Care Staff and explained the reason for the visit. 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 masks. Additionally, LPA was screened by staff at the front door. LPA explained to Ms. Teibel that while LPA was investigating complaint #25-AS-20211008112012 and reviewing records, LPA observed that R1 had a missed medication error on R1's Medication Administration Record (MARS). The following deficiencies were observed at today’s visit (see LIC 809D ) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted, report copy was emailed to Licensee, and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 16, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Dec 16, 2021

Incidental Medical and Dental Care Services 87465(a)(5). The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: licensee did not ensure that staff provided R1's medication as prescribed by a physician. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 16, 2021

Plan of correction: Licensee agrees to ensure that all staff are assisting residents with the proper dosages of medications. Licensee will send to CCL a written plan for training and scheduling to show training; shadowing and successful med passes before all staff are to be working alone by 12/17/2021.

Type of visit: Case Management - Deficiencies

On 09/23//2021, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced Case Management Health and Safety visit as directed by the department. LPA met with Administrator Licensee Gurmeel Singh and explained the reason for the visit. 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 masks. Additionally, LPA was screened by staff at the front door LPA toured the facility inside and out including but not limited to facility dining areas, outside areas, staff break rooms, kitchen area. LPA observed that the facility has had some renovations done. The following renovations has been completed included; Bathroom remodeled, added counters, cabinets in the kitchen area, new flooring and painting throughout facility, a wall that has been removed, bedrooms and bathrooms has been added. LPA asked Licensee if there was a permit application on the changes to the facility. Licensee reported that “my architect is in the process of getting that completed.” LPA explained to Licensee that when there are any kind of alternations to the facility, licensee needs to report such changes and a permit completed prior to the remodel, which also needs to be approved as well as a fire inspection completed. Licensee reported that he was not aware of having to notify LPA but will from now on. LPA asked about residents in care and where have they been throughout the remodeling. Licensee reported that all residents in care have been removed from the facility in process of remodeling. continue on 809-C LPA requested to see documentation that residents and families have been notified of the movements. Licensee reported that they never provided any documentation regarding the moves and that they have been in contact with all residents and their families verbally. LPA explained to Licensee that LPA will be citing Licensee regarding the unreported alternations in the facility, reporting requirements to LPA on changes, no fire clearance on renovations, and illegal evictions. Licensee understood and reported that he will contact LPA with any changes to the facility from here on out. Deficiencies are cited on LIC 809D. Exit interview conducted and a copy of report along with appeal rights were giventhe state’s words, verbatim · CDSS document, Sep 23, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Oct 1, 2021

Alterations to Existing Building or New Facilities (a)Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidence by: The licensee has made some alterations to the facility and did not seek approval from the licensing agency or the fire marshal, as required. This poses an as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2021

Plan of correction: Licensee agrees to submit a floor plan to the licensing agency that indicates the physical floor plan changes. Licensee shall submit the floor plan to the licensing agency by 10/01/2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR87202 · Plan of correction due date: Oct 1, 2021

All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...or the State Fire Marshal. This requirement is not met as evidenced by: Based on LPA observation, licensee did not maintain a fire clearance to the alternations made at the facillity. This poses an as a otential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Sep 23, 2021

Plan of correction: Licensee agrees to get Facility renovations cleared by the fire Marshal and provide clearance to LPA by 10/01/2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224 · Plan of correction due date: Oct 1, 2021

Eviction Procedures. (a) The licensee may evict a resident for one or more of the reasons listed ... This requirement was not met as evidenced by: all residents were moved during facility alterations and not given an approriate 60 day notice. This posed a potential risk to resident's personal rights.the state’s words, verbatim · CDSS document, Sep 23, 2021

Plan of correction: Licensee agrees to submit a statement of understanding of this regulation to LPA by 10/01/2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Oct 1, 2021

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the... Based on LPA observation, licensee did not maintain a fire clearance to the alternations made at the facillity. This poses an as a otential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Sep 23, 2021

Plan of correction: Licensee stated that a written plan will be submitted to Licensing stating how facility can ensure a written report is submitted to Licensing and Responsible Party of residents in the future by 10/01/2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 07/07/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Brenda Myers (Admin) and explained the purpose of the visit. Prior to initiating the 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; contacted licensee 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: N-95 Masks. LPA and Brenda Myers toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) of six (6) resident bedrooms, three (3) of three (3) bathrooms, kitchen, garage, staff office, and backyard. . LPA checked lock on gate surrounding the Pool and ensure it was locked. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time. LPA is requesting the following documents to be submitted by COB 7/23/2021 via fax at (916) 263-4744: Control of Property; Limited Liability Insurance. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jul 7, 2021