Penngrove Shangri-La

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. visit of the facility. LPA was welcomed by staff Joyce Torres. LPA met with Teddy Rico, Licensee. There is a total of 6 residents and 3 with a diagnostic of dementia. There is one resident currently on Hospice. LPA toured the facility on 8/3/2023 at 10:50 AM with licensee, Teddy Rico; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices which were working properly at the time of the visit. Fire Extinguisher was found to be last charged on 1/23/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 114.9 degrees F and 115.8 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility on 8/3/2023. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Sharps were stored in locked drawer in kitchen although some knives were also observed by LPA and licensee on 8/3/2023 at 11:01am in unlocked kitchen drawer (see LIC809-D). Toxins stored in a cabinet in the garage has broken lock (see LIC809-D) and exit door from kitchen to garage was turned off at the time of the visit on 8/3/2023 at 11:05 am (see LIC809-D). There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 8/3/2023 at 11:10 AM. Continue on LIC 809-C A review of five resident & four staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 11:45 AM on 8/3/2023 and learned that 3 of 5 residents have an updated re-appraisals/needs (R1 & R2 re-appraisals have not been updated see LIC 809-D) & care plans and physician’s assessments (LIC 602A). Medications were centrally stored in a locked cabinet, pre-poured (see LIC9102 TV) in the facility kitchen area; although during tour on 8/3/2023 at 10:55 am with licensee, medications to be disposed were found in kitchen cabinet not containing a lock (see LIC 809-D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 8/3/2023 at 10:00 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPA reviewed a sample of staff records at 8:45 AM on 8/3/2023 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2022 are on file. LPA was presented with proof of CPR & 1st Aid although 1 of 4 staff did not have current 1st Aid (see LIC 809-D) certification for staff that files were reviewed. Jordan Rico Administrator Certificate # 6039905740 expires on 5/19/2024. LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information other than the mobile phone number. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted often with the last one being conducted on 5/19/2023. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.. Continue on LIC 809-C LPA Hansen is requesting Licensee to submit update documents to CCL by 9/3/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of updated Lease Agreement Copy of Administrator Certificate Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Aug 3, 2023

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

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

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Case Management Legal/Non-compliance inspection and met with staff Jesus Briones. Administrator Maria Bacani was unavailable during time of visit. The inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. LPA toured the facility, all exits were unobstructed. Facility has a COVID-19 screening station (visitor sign-in sheet, thermometer, hand sanitizer). LPA recommended facility add a COVID questionnaire (with screening questions) to their sign-in sheet. Staff and resident's temperatures are taken daily and documented. Facility food supply was inspected and found to be within regulation. There are a total of 5 smoke detectors and 1 carbon monoxide detector, which were tested and observed operational. Fire extinguisher was charged and serviced 01/07/2022. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. During this visit, LPA verified staff COVID-19 vaccination records. A review of resident and staff records was conducted. LPA discussed the following items with staff: · Facility to document resident Appraisal/Needs & Service Plans on required form LIC 625 (not LIC 603A) annually or when there is a change in condition for resident. · Ensure bathrooms have a garbage can with lid at all times · Implement a COVID questionnaire in visitor sign-in binder to ensure all visitors are being asked the screening questions LPA requested the following items be submitted to the California Department of Social Services, Community Care Licensing by 11/07/2022: · Infection Control Plan copy · Monkey pox Addendum to Infection Control Plan copy · Documentation on completion of N-95 Respirator FIT testing for staff (Cal/OSHA requirement). Exit interview conducted with staff Jesus Briones, whose signature on this document confirms receipt. **No deficiencies cited during this inspectionthe state’s words, verbatim · CDSS document, Oct 19, 2022

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Annual 1 yr. Required & Case Management Non-Compliance Infection Control inspection to this facility and was welcome by staff Jesus Brioles. Facility has 4 residents with no one on hospice care at this time. Facility has activities for residents during the day. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 6/2/2022 with staff Jesus Briones, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, garage, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/2022 at the time of the visit. LPA conducted a sample test of Smoke Detectors & Carbon monoxide detector and they were operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Facility has no residents with special dietary need at this time. Food is available for residents any time of the day. Facility takes residents on walks, and conduct activities during the day such as singing. LPA observed during this visit unlocked toxins – Lysol under residents' bathroom and several different toxins under kitchen sink which is not locking properly. LPA was able to open the under-sink door without magnetic device. In addition, staff room wasn’t locked and had over the counter medications unlocked on top of dresser and unlocked garage with unlocked toxins. Sharps such as knives and scissors were found unlocked in a kitchen draw and countertop while staff S1 and S2 on shift were touring facility with LPA. Facility at this time has 2 out of 4 residents with a diagnosis of dementia. There was a supply of cleaners, hygiene products and paper products available for residents. (see copies, Picts, LIC 809-D) Continued LIC 809-C All bathrooms designated for residents at the facility were supplied with single paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Facility hot water temperature at residents' bathroom faucet measured between 118.8 degrees F and 120 degrees F in 2 out of 2 residents’ faucets within Title 22 acceptable regulations of 105 to 120 degrees F. All staff on shift during this visit is fingerprint cleared and associated to facility. During residents' file review due to unlocked toxins and sharps, LPA learned that there are 2 out of 4 residents' with reappraisals over 12 months. Resident R1 – diagnosis of dementia most resent reappraisal dated 9/28/2020 and Resident R3 – diagnosis of MCI reappraisal dated 11/2/2020. (see copies, LIC 809-D) Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in small storage cabinet in living room. Facility has hired staff and admitted new residents since COVID-19. Residents’ medications are stored and locked in kitchen cabinet. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; licensee/admin stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Visitors are being allowed in the facility. Residents have also available virtual and telephone calls when contacting with family members and others. Staff stated that all PPE training required and N-95 fit testing are on file. Disaster Drills have been conducted quarterly with the last one being conducted on 5/10/2022. Facility still has pending updated fire clearance. LPA contacted Fire Marshall AT who stated that another visit will be conducted. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Jun 2, 2022

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

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

Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Case Management Non-Compliance Infection Control inspection to this facility and was welcome by Administrator Cora Bacani. Facility has 4 residents with no one on hospice care at this time. Facility has activities for residents during the day. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 2/3/2022 with Administrator Cora Bacani, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, garage, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/2022 at the time of the visit. LPA conducted a sample test of Smoke Detectors & Carbon monoxide detector and they were operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Facility has no residents with special dietary need at this time. Food is available for residents any time of the day. Facility takes residents on walks, and conduct activities during the day such as singing. Toxins are stored in a locked garage cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Facility hot water temperature at residents' bathroom faucet measured between 115.8 degrees F and 117.6 degrees F in 2 out of 2 residents’ faucets within Title 22 acceptable regulations of 105 to 120 degrees F. In addition, Department learned that staff S1 has been working in the facility since 11/2021, however; she is not fingerprint cleared according with Guardian. LPA w/ administrator contacted office staff at Regional Office and confirm that staff is not fingerprint cleared and there was no information regarding why it is taking this long (see confidential name list, LIC 809-D, civil penalty) Continue LIC 809-C Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in small storage cabinet in living room. Facility has hired staff and admitted new residents since COVID-19. Residents’ medications are stored and locked in kitchen cabinet. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; licensee/admin stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file. In addition, facility is allowing visitors in the facility. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and is working towards N-95 fit testing. LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted with the last one being conducted on 10/23/2021. Administrator understand that disaster drills must be conducted quarterly and in different shifts to ensure that all staff will participate as per Health & Safety Code #1569.695 Emergency Plans. Immediate Civil Penalties are being assessed in the amount of $500 due to staff not being associated to the facility. *****Total Civil Penalties issued today in the amount of $500.00 Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Feb 3, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Feb 4, 2022

87355(e)(1) Criminal Record:All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:Obtain a California clearance or a criminal record exemption ... This requirement is not met as evidenced by:Based on obs. & file review,the licensee didnot comply w/section cited above in 1 out of 2 staff fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.LPA interviewed Adm & learned that staff S1started working on 11/20/21,however has no fingerprint clearance>(CP)the state’s words, verbatim · CDSS document, Feb 3, 2022

Plan of correction: Facility to ensure that all staff is fingerprint cleared and associated to the facility before working in a licensed facility. Facility to submit a self certification to the Department as proof that staff S1 who is not fingerprint cleared will not be working, voluntering, and/or residing at the facility until fingerprint cleared by POC date of 2/4/2022.

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Case Management Health Checks inspection to this facility and was welcome by Mary Quiambao - staff. Administrator Cora Bacani was contacted by phone and spoke with LPA during visit. Facility has 5 residents with no one on hospice care at this time. Facility has activities for residents during the day. Facility has built a four wall room in the garage (picture on file) that was being used as a staff room. However, facility didn't acquire a permit and has no fire clearance for the garage room. Penngrove Fire Marshall contacted Department stating that room can only be used as a break/storage room and is waiting for fire alarm system before clearing room in garage for such. Administrator Cora Bacani understands that garage room can not be used as staff room at this time and will have mattress against the wall in this room removed. Penngrove Fire Marshall will be returning to the facility as per administrator Cora Bacani on 10/7/2021. In addition, LPA reviewed files for residents due to a concern from Penngrove Fire Marshall regarding bedridden resident in a room designated for non-ambulatory. Per record review of 5 residents LIC 602 ambulatory status, there are 3 ambulatory & 2 non-ambulatory residents. (see LIC 811) There were no deficiencies cited at this time.the state’s words, verbatim · CDSS document, Sep 30, 2021

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

Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Case Management Non-Compliance Infection Control inspection to this facility and was welcome by Jesus Briones. Administrator Cora Bacani was contacted by staff an arrived during the visit. Facility has 5 residents with and no one on hospice care at this time. Facility has activities for residents during the day. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 9/9/2021 with Administrator Cora Bacani, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. However, LPA observed that garage has a room built a staff room in the garage which has not been fire cleared as per Title 22 Regulations and Health & Safety Code requirements. (see pictures, LIC 809-D, Civil Penalty) During TSP – Technical Support Program that the Department offered the facility to ensure compliance, it was discussed with facility licensee Teddy Rico and Administrator Cora Bacani the process to have a staff room build in the garage. LPA Fernandes-Goes at different occasions question administrator if facility was still planning to build a staff room in the garage. Administrator and licensee didn’t follow the process. At today’s visit LPA observed a room in the garage and inside the room it was observed bed with sheets, blanket, pillows, medications for staff S1, TV, dresser, money, as well as stored items. (see copy of sketch & pictures) Resident’s bedrooms, common areas, garage, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/2020 at the time of the visit. Smoke Detectors & Carbon monoxide detector were operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Facility has no residents with special dietary need at this time. Food is available for residents any time of the day. Facility takes residents on walks, and conduct activities during the day such as singing. Toxins are stored in a locked garage cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. Continue LIC 809-C All bathrooms designated for residents at the facility were supplied with towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Facility hot water temperature at residents' bathroom faucet measured 114.2 degrees F within Title 22 acceptable regulations of 105 to 120 degrees F. Continue LIC 809-C Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in small storage cabinet in living room. Facility has hired staff and admitted new residents since COVID-19. Residents’ medications are stored and locked in kitchen cabinet. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; licensee/admin stated that they are able to wear masks when going on outings. All staff had masks on during this visit, however; staff S1 had mask on neck and stated that was eating at the time. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32-ASC & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19) In addition, facility to follow updated guidelines for visitors according with PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19) In addition, facility allowing visitors in the facility. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have had N-95 fit testing last 12/2020. Continue LIC 809-C LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted with the last one being conducted on 7/17/2021. Administrator understand that disaster drills must be conducted quarterly and in different shifts to ensure that all staff will participate as per Health & Safety Code #1569.695 Emergency Plans. In addition, LPA gather more information regarding incident report that was submitted to the Department by the facility. Civil Penalties are also being assessed in the amount of $500 due to zero tolerance citation issued. *****Total Civil Penalties issued today in the amount of $500.00 Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Sep 9, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Sep 10, 2021

Fire Clearance:All facilities shall maintain a fire clearance approved by the city,county, or city & county fire department, or district providing fire protection services... This requirement is not met as evidenced by: Based on observation & interview licensee didn't comply with this section above in 1 of 1 facility fire clearance on file which poses an immediate risk to health & safety of residents in care. Facility has a staff sleeping rest area room that was build in the garage. (see pic, CP)the state’s words, verbatim · CDSS document, Sep 9, 2021

Plan of correction: Licensee to breakdown the staff sleeping area in the garage and immediately stop having staff sleep in the garage. Licensee to submit photos of the garage space cleared of the staff sleeping area/items as described in the report.Licensee also toensure that staff won't be sleeping in facility common areas and/or submit updated sketch for fire clearance & maintain no staff until clearance granted. Submit POC no later than 9/10/2021.