Modesto Guest Home

Type of visit: Required - 1 Year

On 03/22/2023 at 1:00pm, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct an Annual Visit. LPA Pascua was greeted by Facility Designated Administrator (FDA) Guillermina Zepeda and explained the purpose of the visit. Current census was 30. A brief interview was conducted with FDA Zepeda. This facility is licensed for 31 residents, of which 25 may be non-ambulatory. LPA reviewed 6 resident files. 6 out of 6 resident files were current and up to date. LPA reviewed 6 staff files. 6 out of 6 staff files were current and up to date. The facility Administrator has an administrator certificate #6025364740 and is awaiting renewal from the department. LPA Pascua observed a locked centralized stored medication cabinet located in the office. Along with the staff member, the LPA observed, reviewed, and compared resident medication and electronic medication dispensing logs. First Aid Kit was present and contained all of the required components. A tour with FDA Zepeda was conducted. Fire extinguisher located throughout the facility. was serviced by U.S.A. Stanislaus Fire on 06/16/2022. Carbon monoxide, smoke detectors and call lights were observed to be in good repair. Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time. Kitchen area was toured. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care. Additional food supply was identified in an outside storage. A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time. A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A tour of the second building was conducted. Dining areas, living areas, and all other areas intended for resident use were toured in this building. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time. The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair. The following forms and documents were requested to be updated and submitted into CCL. -LIC 308 -LIC 400 -LIC 500 -LIC 610 Per California Code of Regulations, Title 22 Division 6, Chapter 8, one deficiency is being cited today in violation of California Code of Regulations. An exit interview was conducted, a copy of this report and appeals rights were provided to the Administrator at the end of this visit.the state’s words, verbatim · CDSS document, Mar 22, 2023

Allegation investigated: Staff did not prevent resident from engaging in inappropriate behaviors with another resident Staff did not prevent resident from making inappropriate comments towards another resident Staff are not providing a comfortable environment for resident

Licensing Program Analyst (LPA) Arielle Pascua and Licensing Program Manager (LPM) Stephenie Doub conducted an unannounced facility visit to deliver compliant findings. LPA Pascua and LPM Doub met facility designated administrator, Guillermina Zepeda and explained the purpose of the visit. Throughout the course of this investigation, LPA Pascua conducted interviews and reviewed facility documents. Based on interviews conducted with 4 residents on 05/04/2022 and 07/05/2022, it was learned during 1 resident interview that another resident has been video recording him against his will and has talked to staff about it but nothing has been done to mitigate the issue. Administrator stated that they have observed resident with the phone only playing video games and does not believe that phone has a recording capabilites. Unsubstantiated 1 of the 4 residents denied any issues with residents. 2 of 4 residents were not reliable witnesses due to medical conditions. Staff was also interviewed during this investigation. Staff stated that when there are any alternations between residents they respond with the appropriate means to mitigate the situation. Staff members also stated they try to get ahead of any alternations between any residents before an incident may happen and they are told to separate residents in separate areas of the facility when needed. Based on a resident interview, they confirmed that staff responds to any issues between residents in a timely manner. Based on information provided through interviews and records reviewed, these allegations are deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported. A exit interview was conducted, and copy of this report given to the facility.the state’s words, verbatim · CDSS document, Jul 5, 2022 · control 27-AS-20220504101912

Allegation investigated: Staff are speaking to resident in an inappropriate manner

Licensing Program Analyst, Albert Johnson visited the facility today to deliver findings for a complaint investigation for the allegation listed above. LPA spoke with Guillermina Zepeda, Administrator (AD). Allegation: Staff are speaking to resident in an inappropriate manner. Based on interviews conducted with 6 residents on 3/7/2022, 5 of 6 residents stated that the facility staff address them with respect and one residents confirmed that the staff usually address each resident with respect. LPA was informed by that resident about an incident that happened on or about 2/22/22, the Lead staff for the day was not speaking to them in an appropriate manner. LPA was informed by the resident that the incident was personal and involved using the bathroom in an area that was not intended to be used as a bathroom. Continued Unsubstantiated LPA was told by this resident that the "The Lead Staff questioned them about using the bathroom in this area of the building and it made them feel bad and a little embarrassed." LPA asked if the staff used bad words or called them names? The residents stated "No". LPA asked if there were any other issues with staff talking inappropriately toward residents. All residents interviewed denied that staff speak to resident in an inappropriate manner. Based on information provided through interviews and records reviewed, these allegations are deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.the state’s words, verbatim · CDSS document, May 17, 2022 · control 27-AS-20220228152227

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Annual / Infection Control Inspection visit on this date. LPA met with Guillermina Zepeda, Administrator (AD). Administrator Certificate expires March 21, 2023. LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas. LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 115.2 F degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees. Fire extinguishers expires May 24, 2022. Fire alarm and carbon monoxide functional. LPA observed centrally stored medications locked. LPA observed toxins stored in locked cabinet. LPA reviewed four staff and four resident files. Resident emergency contact complete. LPA observed all staff files complete. All staff completed CPR class on 10/9/2021. All persons in facility fully vaccinated with exception of 2 residents due to personal reasons. LPA observed resident practicing social distancing. LPA observed 30 days of PPE supplies. LPA observed the required postings displayed. LPA observed sharps stored in kitchen and kitchen door locked. Per California Code of Regulations, Title 22 Division 6, Chapter 8, one deficiency is being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report and appeal rights given to AD.the state’s words, verbatim · CDSS document, Mar 11, 2022

Allegation investigated: Staff handle resident in care in a rough manner. Facility is not safeguarding resident(s) belongings.

Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced complaint visit on this day for the purpose of concluding a complaint investigation. On this day LPA met with Guillermina Zepeda, Administrator (AD) and advised the purpose of LPA's visit. The initial 10-day visit was conducted on 12/8/2021. Through the course of the investigation, LPAs conducted interviews and reviewed staff and resident records. It was alleged that the staff handle resident in care in a rough manner. LPA interviewed representatives from PACE that provided direct support services to residents that PACE places at the facility. PACE representatives stated they have placed residents in care at facility in the past and have had no concerns of the care being provided from the facility. PACE representatives confirm they visit 3x per week and have not observed any concerns. PACE stated residents come to their facility and have not observed any concerns of the residents when at their facility. LPA attempted to conduct interviews with residents. LPA was only able to interview 1 of the 5 residents as not all residents were able to be interviewed due to inability to be a reliable historian. LPA interviewed responsible parties and staff of R1 who stated that R1 is not a reliable historian. LPA toured facility and observed residents were being cared for properly. It was unclear if staff handle resident in care in a rough manner as alleged. Due to this uncertainty, the allegation that staff handle resident in care in a rough manner was deemed unsubstantiated. CONT. >>>>>>>>>>>>>>>>> Unsubstantiated It was alleged that facility is not safeguarding resident(s) belongings. It was reported by R1 that items were missing when facility brought R1 to hospital. Interviews conducted with responsible party of R1 confirm items were not missing and found by the nurse at the hospital. LPA toured the facility and found residents belongings and personal effects in their rooms. Interviews conducted confirm R2 concerned of R2s belongings when R2 is given a shower. Through interviews, facility has a procedure to ensure R2 feels R2s belongings are safeguarded. Not all clients could be interviewed due to inability to be a reliable historian. It was unclear if facility is not safeguarding resident(s) belongings as alleged. Due to this uncertainty, the allegation that facility is not safeguarding resident(s) belongings was deemed unsubstantiated. Based on information provided through interviews and records reviewed, these allegations are deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported. Copy of this report provided to Administrator Guillermina Zepeda, Administrator (AD).the state’s words, verbatim · CDSS document, Dec 22, 2021 · control 27-AS-20211203154141

Type of visit: POC

Licensing Program Analyst (LPA) Arlene Garcia made an unannounced POC visit to the facility to verify correction of citations issued during the Infection Control/ Annual visit on 12/08/2021. LPA reviewed documents required per the POC. LPA toured and observed physical plant corrections were made. Deficiencies cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date. Facility was provided POC cleared letter. Exit interview conducted and a copy of this report was provided to Guillermina Zepeda, Administrator (AD) .the state’s words, verbatim · CDSS document, Dec 22, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA met with Guillermina Zepeda, Administrator. LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas. LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 105.3 degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees. Last Fire Drill conduced dated 7/14/21. Fire extinguisher maintained 05/24//2021. Fire alarm and carbon monoxide functional. LPA observed centrally stored medications in office with the office door open and unlocked. LPA observed medications on desk and medication cabinet unlocked. LPA observed animal feces under sink in front detached building. LPA observed toxins stored in locked cabinet and additional toxins in rolling cart latched but not locked. LPA reviewed 10 of 10 staff and 15 of 30 resident files. Resident emergency contact complete. LPA observed all staff files complete. All staff completed CPR class on 10/9/2021. All persons in facility fully vaccinated with exception of 2 residents due to personal reasons. LPA observed resident practicing social distancing. LPA observed 30 days PPE supply. LPA observed the required postings displayed. Administrator Certificate valid until 4/18/2022. LPA observed sharps stored in kitchen and kitchen door locked. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.the state’s words, verbatim · CDSS document, Dec 8, 2021

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Dec 9, 2021

87465(h)(2) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: During tour of facility, LPA observed unlocked medications in front office with the door open. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 8, 2021

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Dec 9, 2021

87309(a) Storage Space. (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: LPA observed unlocked cleaning cart in outdoor walkway unattended. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 8, 2021

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Dec 9, 2021

80087(a) Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by LPA observed animal feces under sink in front building in community kitchen area. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 8, 2021