Sonoma Grove

Type of visit: Required - 1 Year

Licensing Program Analysts Cuadra and Coppo arrived unannounced to conduct an Annual Required Inspection and met with Licensee/Administrator, Alex Varshavsky. Licensee/owner Julia Latifi arrived later. Facility currently has Hospice Waiver for 10 residents including 2 bedridden residents allowed. LPAs/Administrator initiated a tour of the facility around 9:00am and made the following observations: Facility was a comfortable temperature. Passageways were free from obstructions. Not all resident rooms were furnished per Title 22 regulation 87307(3)(B): room numbers 2,3,4,and 9 all were missing a lamp for each resident, Technical Advisory given. Water temperature in sink accessible to residents in care measured at 102.2 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars.Facility has at least two days of perishable and seven days of non-perishable foods. Required postings were observed. At approximate 9:15am LPAs/Administrator observed 4 out 5 fire extinguishers were last inspected 09/28/2022 which is out of compliance per Title 22 regulation 87202(a). Smoke alarms/Carbon Monoxide detectors were tested and operational per fire inspection tag serviced on 02/10/2023. Last fire drill conducted 09/14/2023. At approximately 10:00am LPAs/Administrator started file review of five staff files and ten resident files. 10 out of 10 residents' Care Plans were not signed by a responsible party as required per Title 22 regulation 87463(c). R10 did not have a care plan and their admission agreement was not signed by their responsible party. Also, residents (R7 and R9) who have a diagnosis of dementia, did not have a current medical assessments within the last 12 months as required per regulation. LPAs discussed with Administrator the importance of having care plans, medical assessments, and admission agreements signed. Administrator agreed to update residents' files to be in compliance with Title 22 regulations to avoid further citations. Continued on LIC809C continued from 809.. At approximately 12:30pm LPAs/Licensee found that 5 out of 5 staff members did not have their training records. The records were not maintained or updated. 3 out of 5 staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Alexander Varshavsky 6052513740 expires 07/03/2023 (pending). LPAs/Licensee had a discussion about staff training record requirements and Licensee agreed to review and update staff records as well as implement organizational system. At approximately 1:30pm LPAs/Administrator conducted a spot check of medications and observed residents' (R2, R11, R12, R13 & R14) medications are been crushed. However, LPAs were informed by Licensee that there are no physician's crush orders on file to crush medications for residents as required per regulation 87465 (a)(5)(D). Also, Centrally stored medication records have not been maintained current as required by 87465 (a)(6). Based on record review, the facility has not contacted a pharmacy to review their medication management at least twice per year as required by regulation H&S 1569.69 (g). At approximately 2:00pm LPAs/Administrator observed facility's resident alert signal does not produce auditory signal loud enough to alert staff when residents need assistance as required per regulation 87303 (i)(1)(B). Administrator provided LPAs a copy of their liability insurance and a copy of current lease. Licensee/Administrator to submit updates of the following documents by 11/02//2023: LIC 308 Designation of Responsibility forms. LIC 500 Personnel Summary 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 conducted with Licensee/owner and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 19, 2023

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Staff are mishandling resident's medication log.

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at SonomamodelX for the purpose of delivering complaint findings. LPA was greeted at the door by Med Tech/Receptionist, Juliana Sanchez, and was granted access into the facility. During the course of the investigation, LPA Sarangi reviewed facility records including the Medication Assessment Record (MAR). Complaint alleges that Staff are mishandling resident's medication log. During the opening of the complaint on April 27, 2023, LPA reviewed the Medication Assessment Record (MAR) with the Administrator for the month of April 2023 and learned that tracking of the medication was not being documented as outlined in the facilities Program Plan of Operation. LPA reviewed the Program Plan of Operation/Program Philosophy on May 18, 2023. (Report continued on LIC 9099C) Substantiated and observed on page 4 & 5 of the Program Plan of Operation/Program Philosophy it indicates the following, "All medication assistance will be documented with the medication name, time, date and dosage taken by the resident, or documentation that the resident did not take the medication according to the prescription. All documentation will be accompanied by a signature of the trained staff member that has passed the medication. This will include any type of medication pass." (See LIC 809D and Document Review-Program Plan of Operation/Program Philosophy) 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, and a copy of this report was signed by the Med Tech/Receptionist, Juliana Sanchez and emailed to the Administrator due to printer issues. Complaint alleges that Staff has not address scabies outbreak in facility. Based on the interviews that were conducted with the facility and an outside agency, LPA learned that the facility reported the Scabies outbreak via facsimile to the appropriate Public Health Entity. Furthermore, LPA received proof that the facility reported to their respective Public Health Entity. An incident report was forwarded to Santa Rosa Regional Office on April 3, 2023 indicating that the facility had an outbreak of scabies and that the facility was following their Infection Control Plan. Complaint alleges that Staff are not meeting resident care needs. Based on interviews that were conducted with residents in care and a witness, LPA could not prove or disprove the allegation due to inconsistent statements made during the course of the investigation. Complaint alleges that Staff does not ensure resident's room is sanitary and clean. During the opening of the complaint on April 27, 2023 and during a subsequent complaint investigation inspection conducted on May 16, 2023, LPA toured the facility on both dates and observed the facility to be appropriately cleaned and at a comfortable temperature with all exits free from obstruction. LPA observed the facility to be smelling appropriate and observed ALL resident bathrooms. Resident bathrooms observed to be appropriate during the inspection. Resident rooms observed to be appropriate and smelling good during the course of the investigation. Complaint alleges that staff does not ensure resident's medications are properly stored. During the opening of the complaint on April 27, 2023, LPA observed the medication cart was locked and secured. During a subsequent complaint investigation inspection conducted on May 16, 2023, LPA observed medication cart being locked and secured at the time of the subsequent complaint investigation inspection A finding that the complaint allegations of Resident sustained a pressure injury while in care. Staff has not address scabies outbreak in facility. Staff are not meeting resident care needs Staff does not ensure resident's room is sanitary and clean. Staff does not ensure resident's medications are properly stored are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed by the Med Tech/Receptionist, Juliana Sanchez, and emailed to the Administrator due to printer issues.the state’s words, verbatim · CDSS document, Jun 2, 2023 · control 21-AS-20230426161815

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Jun 9, 2023

87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met at evidenced by: Based on observation of the Medication Assessment Record (MAR) during the opening of the complaint on April 27, 2023, LPA observed that the Program Plan of Operation was not being followed as it relates to Medication Policies and Procedures. Furthermore, during a review of the MAR on April 27, 2023, LPA and Administrator observed two residents that did not have the MAR properly documented and had the month of April 2023 missing from the MAR.the state’s words, verbatim · CDSS document, Jun 2, 2023

Plan of correction: Licensee shall submit a LIC 9098 understanding the regulation. In addition, Licensee shall send the most updated Program Plan of Operation. POC due date is June 9, 2023.

Type of visit: POC

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/12/2022 to follow up with Plan of Correction. LPA met with administrator/licensee Alexander Varshavsky. Upon arrival interior temperature was observed at 84 degrees F which is within regulation. Exterior temperature was 85 degrees F during the inspection. LPA and administrator discussed plans going forward to ensure temperature stays within a comfortable range. Licensee intends to purchase portable air conditioners and place them throughout the facility within the week. Licensee has been in contact with air conditioner installers for a centralized and permanent solution. Licensee to submit pictures of portable AC units to LPA. Exit interview conducted with administrator/licensee and a copy of the report was emailed to the licensee.the state’s words, verbatim · CDSS document, Sep 12, 2022

Allegation investigated: Facility is not being kept at a comfortable temperature

Licensing Program Analyst Erik Gonzalez Campos arrived unannounced on 09/08/2022 at approximately 1:30 PM to conduct an initial complaint inspection regarding the allegation that facility is not being kept at a comfortable temperature. LPA met with Licensee/Administrator, Alexander Varshavsky. LPA toured the facility and made observations. The majority of residents were observed congregated in the main common area upon LPA arrival. Facility has placed fans throughout the facility and facility staff were observed providing residents with water, popsicles and cooling towels. Fans were observed in all resident bedrooms inspected. LPA observed facility thermostat reading 87 Degrees Fahrenheit in common area despite attempts to cool the area with fans. The recorded exterior temperature was 105 degrees at the time of the inspection. Regulation requires facilities to cool interior temperature to between 78 and 85 degrees F or in cases of extreme heat to 30 degrees less than the outside temperature. Facility does not currently have a centralized air conditioning unit. Continued on LIC 9099C Substantiated The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given. Exit interview conducted with administrator/licensee and a copy of the report printed for the facility.the state’s words, verbatim · CDSS document, Sep 8, 2022 · control 21-AS-20220908090203

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b)(2) · Plan of correction due date: Sep 9, 2022

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Based on observations this requirement was not met as evidenced by: LPA observed an interior temperature reading of 87 degrees F while exterior temperature was 105 degrees F during inspection on 09/08/2022 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 8, 2022

Plan of correction: Facility will ensure a plan is put in place to reduce the temperature in the facility per regulation for extreme heat. LPA discussed various options within the community including possible cooling stations. Plan to be submitted to Community Care Licensing by 09/09/2022.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a case management inspection and met with Licensee, Julia Latifi. The purpose of this case management inspection is to follow up on citations given at annual inspection on 8/9/2022 and two self reported incident reports submitted to Community Care Licensing (CCL) 8/22/2022. CCL received a self reported incident report reporting on 8/20/2022 after dinner, resident (R1) had an unwitnessed fall and was found on the floor next to R1's vomit. R1 was sent out to the hospital. During today's inspection LPA was informed R1 was brought back to the facility the following day after tests confirmed R1 had a UTI and was given antibiotics and R1 is back at baseline. LPA obtained additional information regarding a second self reported incident report reporting also on 8/20/22 at 9:30PM caregiver was conducting last shift round and checked on R2, diagnosed with dementia. Caregiver found blood in R2's brief's. R2 was seen at the ER where irritation on upper inner thigh area was found, which R2 had been scratching. Anti itch cream was prescribed and R2 returned to the facility the next day. R2 is back at baseline. LPA was following up on citations given for staff not being associated to facility at annual visit. LPA reviewed personnel list for the day, 8/23/2022 and all staff are cleared and associated to the facility. No deficiencies cited during today’s inspection.the state’s words, verbatim · CDSS document, Aug 23, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Hansen conducted an unannounced Case Management inspection to this facility and met with Julia Latifi, Licensee who arrived at 8:45 AM. The purpose of today’s inspection is to amend LIC 809/809C/809C-2/809-D from Annual inspection conducted on 8/9/2022. LPA issued citations 87355(e)(1) Criminal Record Clearance for 3 staff not being fingerprint cleared & 87355(e)(2) transfer of criminal record clearance or association to facility for 1 staff not being associated. Upon further review, LPA arrived today to issue civil penalties for citations issued on 8/9/2022. Civil Penalties in the amount of $300.00 and $100.00 are being assessed. See Amended 809/809C/809C-2/809-D from Annual inspection 8/9/2022 LPA requested copy of current LIC500 Personnel list & LIC 9020 Resident list LPA obtained requested POC from Licensee and cleared POC. licensee understands all staff must be background cleared and associated to facility prior to returning to work or working or more civil penalties will be assessed. No deficiencies cited during today’s inspection.the state’s words, verbatim · CDSS document, Aug 11, 2022

Type of visit: Required - 1 Year

*****AMENDED*****Licensing Program Analyst (LPA), Shannan Hansen arrived unannounced to conduct a required 1-year Infection control inspection at approximately 8:50 AM, and met with Licensee Julia Latifi. The inspection is focused on the Infection Control procedures and practices of this facility. There are currently 21 residents in care, 13 dementia and 1 on hospice. Upon entry LPA was screened for COVID symptoms and asked to sign in. At primary entrance LPA was temperature checked and provided hand sanitizer and visitor sign in sheet. LPA conducted walk through of the facility with Licensee and observed COVID postings throughout. LPA toured the building and grounds which were found to be clean and in good repair. Facility was a comfortable temperature and all walkways and exits were observed to be unobstructed. The amount of fresh and nonperishable foods is within regulation. Toxins are stored and inaccessible to residents in care. Water temperature measured at 110.3 and 105 degrees F which is within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguisher inspected was charged dated 9/16/2021. LPA was provided with invoice from third party company responsible for inspecting fire safety system which includes smoke detectors and sprinkler system dated March 17, 2022. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings. Hand sanitizer is kept throughout the facility. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation. Toxins are secured and inaccessible in locked housekeeping closets. A 30 day supply of medications are centrally stored and secured. Continued on LIC 809C Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPA and staff discussed resident activities which include bingo and music. Visits are occurring both indoors and outdoors. Residents do not frequently leave the facility but there are procedures in place to screen residents when returning from outings. Infection Controle: Facility has submitted a mitigation program plan that was approved, and Infection Control Plan has been requested again on 8-3-22 via email from LPA. All staff, clients, & visitors check in with the electronic temperature and log, and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in hallway closet and in garage. Staff had all PPE training required on file as well have been N95 Fit Tested. LPA reviewed Licensing Information System (LIS) with Assistant Administrator who stated that is correct other then Administrator no longer works at facility and a new one will be replacing in a couple of weeks, at this time; no need to change any of the information. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted every 3 months with the last one being conducted on 6/7/2022. LPA obtained list of staff working at time of visit and checked with current Guardian list which showed: S1 was background cleared and associated to another facility but not associated to this facility. S2, S3, and S4 do not have DOJ background clearance as required by Regulations. LPA discussed with Licensee who agreed to call other staff to cover for unfingerprinted staff. LPA informed Licensee to contact Guardian at 888-422-5669 for clearance of staff and to transfer cleared record, Licensee may call CCL and submit a copy of staff’s current CA or US ID, LIC 508, & LIC 9182. *****AMENDED on 8/11/2022 to issue Civil Penalties for 3 staff not fingerprint cleared and 1 staff not associated. Civil Penalties issued in the amount of $400.00. Facility is being cited today for 87355(e)(1) Criminal Record Clearance & 87355(e)(2) transfer of criminal record clearance or association to facility. LPA was presented with proof of CPR & 1st Aid certification for staff which files were reviewed. Administrator Certificate is for Alexander Varshavsky #6052513740 Exp. 7/15/2023 All staff and residents have received COVID booster vaccinations and inclusively work at this facility. Continue on LIC809-C2 LIC 809C-2 LPA was presented with proof of CPR & 1st Aid certification for staff which files were reviewed. Administrator Certificate is for Alexander Varshavsky #6052513740 Exp. 7/15/2023 All staff and residents have received COVID booster vaccinations and inclusively work at this facility. 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.. LPA Hansen is requesting Licensee to update and submit the following documents by 8/31/2022 to RPRO: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 610E-S Supplemental Emergency Disaster Plan for RCFE LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate Proof of Liability Insurancethe state’s words, verbatim · CDSS document, Aug 9, 2022

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff are not consistently screening visitors for COVID-19 symptoms prior to entering the facility. Residents are not wearing masks in communal settings.

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Maria Flores and discussed the findings. During the course of this investigation site visits to the facility were made and observations taken; Records and documents were obtained and reviewed; statements were taken from staff, residents, and witnesses. The following determinations are made: While not required by regulation, the facility's mitigation plan calls for residents to wear masks in communal settings if tolerated; residents have been observed without masks in communal settings; most residents have a diagnosis of cognitive decline and cannot be relied upon to give factual statements; staff indicate that most residents do not tolerate masks and often complain or remove them from the face; With the exception of the Complainant, eight out of eight witnesses interviewed stated that the Covid protocols are followed by the staff when witnesses have visited the facility. While the allegations may be true, based upon the records reviewed and statements taken, the preponderance of evidence standard has not been met. Therefore, the allegations are UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 9, 2021 · control 21-AS-20211013124957

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), Erik Gonzalez Campos arrived unannounced to conduct a required - 1 year inspection at approximately 12:15 PM, and met with owner Alexander Varshavsky. The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry LPA was screened for COVID symptoms and asked to sign in. At primary entrance LPA observed thermometer, hand sanitizer and visitor sign in sheet. LPA conducted walk through of the facility with owner and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per owner, updated infection control guidelines and PINs are communicated to residents and responsible parties verbally. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation. LPA provided guidance to contact local public health for infection control/PPE training for staff. Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked housekeeping closets. A 30 day supply of medications are centrally stored and secured. Facility is currently not testing per CCL guidelines since vaccination rate for staff and residents is greater than 70 percent. Continued on LIC 809C Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPA and staff discussed resident activities which include trivia and music. Visits are occurring both indoors and outdoors. Residents do not frequently leave the facility but there are procedures in place to screen residents when returning from outings. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Aug 6, 2021

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Erik Gonzalez Campos conducted an unannounced POST licensing inspection of this licensed senior care facility and was greeted by administrator Maria (Ines) Flores. LPA toured the building and grounds which were found to be clean and in good repair. There are currently 17 residents in care. All walkways and exits were observed to be unobstructed. The amount of fresh and nonperishable foods is within regulation. Toxins are stored and inaccessible to residents in care. Water temperature measured at 113.3 and 114.0 degrees F which is within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguisher inspected was charged dated 08/13/2020. LPA was provided with invoice from third party company responsible for inspecting fire safety system which includes smoke detectors and sprinkler system dated November 10, 2020. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings. While at the facility LPA followed up with previously reported incident. LPA examined the locking door knob of R1 (pictures taken). R1 is able to lock/unlock the door from the inside and is allowed to have a key if she wishes. No deficiencies cited during this inspectionthe state’s words, verbatim · CDSS document, Jul 22, 2021