Clover Senior Care

Type of visit: POC

Licensing Program Analysts (LPAs) Cuadra and Coppo arrived unannounced for the purpose of conducting a plan of correction visit and met with back up Administrator Janine Sorensen. LPA is following up regarding deficiencies cited during the August 8, 2023 Annual Required inspection. The following deficiencies have been corrected: 87465(h)(6) - Centrally Stored Medication Log is maintained. During today's visit, LPAs reviewed records including medication for residents in care. The facility has corrected previous deficiencies and items of concern appeared to be in compliance with Title 22 regulations. No deficiencies cited during today's inspection. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 31, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Christi Coppo and Marisol Cuadra arrived unannounced to conduct an Annual required inspection and was greeted by individual (I1). Licensee Ami Kumar arrived later. LPAs observed I1 was providing care to residents at the facility at the time of visit. LPA informed Licensee that I1 is not associated to facility and should never be working and providing care to residents prior to a criminal record clearance or exemption. ***Civil penalties are being assessed in the amount of $100 per day for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance/transfer per two weeks for a total of $500. LPAs/staff initiated a tour of the facility around 9:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Two fire extinguisher was last serviced April 2023. Smoke alarms are hard wired with sprinklers and fire doors on each resident room as well as a fire door in the hallway. Smoke alarms and carbon monoxide detector was tested and operational at time of inspection. Last Disaster drill was conducted on 7/10/23. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Administrator Certificate for Ami Kumar, 6021684740, expires on 11/8/24. Medications were centrally stored and locked. Hot water temperature reading was 113.2 and 110.4 degrees which is within regulation. Continues on LIC809C... Continued from LIC809... LPA initiated file review at 9:30 am. LPA reviewed six residents files and five staff files. All residents files have a current medical assessment and care plans updated within the last 12 months. Staff records have current First Aid/CPR certificates and additional 20 hours of required training. At approximate 11:00am LPA/staff conducted a spot check of medication and found resident's (R1 & R2) medications were not current into the Centrally Stored Medication. Licensee agreed to review and update the Centrally Stored Medication Records. Licensee agreed to submit updates of the following documents by 8/22/23: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Copy of Liability Insurance. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Licensee and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 8, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Licensee, Ami Kumar. LPA is following up on a recently self-report incident at the facility, which resulted in a suspected physical abuse report. SIR Report was submitted to CCL on 12/20/2022 along with SOC 341. On 12/16/22 Resident (R1) who recently moved into the facility. Upon arrival resident started to refuse medication, food, screaming out and swinging at staff when they try to provide incontinence care. Licensee notified their Physician about their behaviors and were advised to give resident a couple more days for adjustment and they will put a referral for hospice services. On 12/19/22 Kaiser sent a therapist to evaluate resident and was told by resident that staff are hitting them. Per incident report, on 12/20/22 R1 punched a staff (S1) in their face. Per Licensee, after the incident they had a talk and was told by R1 that they wanted to go back home and Licensee advised R1 to get stronger so they can return home sooner which R1 agreed. During today's visit, LPA observed R1's fiduciary and Ombudsman were present interviewing R1. LPA also conducted interviews with them, staff and R1. Based on observations, interviews and records review, R1's care plan dated 12/12/22 and Physician's report dated 11/30/22 R1 does not have a diagnosis of dementia, but their mental condition experiences some intermittent confusion. LPA spoke with R1 who did not specify any information nor staff involved with this alleged abuse. Facility investigated incident, but there were no physical signs of abuse observed, responsible parties were notified. Facility conducted a physical assessment to R1 who is always assisted with ADLs and transfers. Based on interviews conducted by Licensee with staff, the allegations are not substantiated. The Department will be reviewing the information obtained to determine if further actions are needed. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Dec 20, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA were greeted by staff and then staff Janine Sorensen arrived later. Licensee, Ami Kumar was not able to come to the facility, but was available by phone and gave authorization to staff to sign the report. There were 6 residents in care present at the facility. LPA arrived at the facility and did not had their temperature checked and logged into a sign-in sheet. LPA/staff discussed the importance of screening visitors. LPA observed that facility have posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene and paper products. Commonly touched surfaces are disinfected at least three times a day. Each resident has their own room in case that needs to isolate and the facility is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Per Licensee, facility has a 100% vaccination rate and received boosters for staff and residents. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Residents receive indoor visitation with their families and facility is able to perform antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes. Facility has submitted their Covid Mitigation Plan and approved on 3/29/21. Facility also has submitted their Infection Control Plan to CCL for review. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are accessible for staff. Facility agreed to provide updates of the following by 8/16/22: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability insurance and Emergency Disaster Plan (LIC610E). Continues on LIC809C... Continued from LIC809... During today's visit, LPA also followed up on three self-incident reports submitted to Community Care Licensing. Per incident report, on 7/15/22 resident (R1) was in living room and got up on their own without a walker, staff was in kitchen motion sensor went off. Staff went to attend R1 and remind them that they need to use the walker, R1 became anxious, agitated and hit staff when staff stepped back and R1 lost their balance when swinging and fell backwards. 911 was called and R1 was sent to Kaiser for further evaluation. Also, resident's responsible party and case manager were notified about the incident. R1 was sent back to the home after all testing ordered were all fine. Doctor discontinued some medications, prescribed new medication Zyprexa and scheduled some follow up appointments to discuss medication changes. Per second incident report submitted, R1 on the same date woke up in the middle of the night and was having delusions, staff contacted Janine Sorensen to discuss about PRN medication use. However, R1 was still up all night confused, tried to get up and fell back to bed. Staff contacted 911 as instructed per Janine and R1 was transported and admitted to the Kaiser Hospital for broken left shoulder and broken left wrist. R1 was scheduled for surgery on 7/22/22 and R1 will be discharged to go to Rehabilitation. LPA was provided with R1's discharge documents dated 7/15/22 instructing to discontinue new medication prescribed Zypresa until discussing further with their doctor. R1 is currently under care of Apple Valley Post Acute and will be discharged back to the home on 8/12/22. On 8/9/22 CCL received another self-incident report. Per incident report, on 8/5/22 motion sensor went off at 5am and staff found R2 on the floor, R2 seemed confused and staff called hospice who advised to get them back to bed, give them 1/2 tab of morphine and a nurse will be sent to evaluate. Upon nurse arrival, R2 was assessed and was sent to the ER for possible hip fracture. R2's responsible party were notified. R2 was evaluated and diagnosed with a broken hip, R2's family decided not to have surgery and R2 was sent back to the facility on hospice. LPA was provided with information that R2's care plan was updated. Hospice nurse placed a wedge between resident's legs and trained staff how to reposition resident. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Aug 9, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with staff, Janine Sorensen. Licensee, Ami Kumar was not able to come to the facility, but she was available by phone and gave authorization to staff to sign the report. LPA conducted risk assessment with Staff at the facility entrance. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet. LPA is following up on a self-incident report received at CCL on 3/28/22 regarding R1's death. Per Incident Report on 3/26/22 staff went to check on resident (R1) to reposition as usual and R1 began to foam at the mouth, their breathing started to change, 911 was contacted immediately and while on the phone then R1 stopped breathing, fire department arrived at the facility they were provided with R1's DNR dated 11/27/17 on file and R1 was declared death at 8:55pm. Responsible parties were notified, police department was also contacted due that resident was not in hospice and they filed a report #22-3419 and coroner's case number is 1-22-0227. During today's visit LPA was informed by Licensee that R1 celebrated their birthday a couples days before their death and resident was a normal behavior and routine after their birthday. LPA also reviewed R1's Physician's report, needs and services plan. Licensee agreed to submit police report and death certification to CCL as soon as they receive it. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Mar 29, 2022

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Lopez and Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility. LPAs were greeted by staff and then Licensee, Ami Kumar arrived later. LPAs conducted a Risk Assessment call with Licensee prior to the visit. There were 6 residents in care present at the facility. 3 residents were on hospice and 3 residents were not. LPAs arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPAs continued tour of the facility on July 21, 2021. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on April 14, 2021 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. There was sufficient amount of supply for both perishable and nonperishable foods 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. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. Facility has submitted a mitigation program plan that has been approved 3/29/21. Per licensee, all staff have been vaccinated. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Staff and residents are being monitored daily and results are documented in a binder for each month. Facility has PPE supplies stored in the storage room. Facility has a 30-day supply of medication for residents. Residents do not typically wear masks inside the facility but have them available. Facility has conducted staff training on infection control. No deficiencies observed or cited during today's Required 1- Year inspection.the state’s words, verbatim · CDSS document, Jul 21, 2021