Ashley's Manor II

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a continuation of the required annual visit at 01:07 PM. The LPA met with facility designee Michelle Parr. Licensee/Administrator was unavailable during today's visit. Entrance interview conducted. During today's visit the following was observed/reviewed: STAFF RECORD REVIEW: LPA reviewed four (4) staff files for, but not limited to: health screening, TB test, training records and fingerprint clearance. All four (4) staff files observed were in compliance with regulation. EMERGENCY DISASTER PREPAREDNESS: During today's visit, LPA reviewed the facility's emergency disaster plan. Emergency drills are conducted quarterly, with the last drill conducted on 08/04/2023. Emergency disaster plan was observed to be complete and updated annually, as required. INFECTION CONTROL: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. INTERVIEWS: During today's visit, LPA interviewed staff and residents. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Oct 12, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:12 PM. The LPA met with facility designee Tina Marie Martinez. Licensee was unavailable during today's visit. Entrance interview conducted. The LPA, along with facility designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are designated for resident use and 1 (one) is designated as a staff room. The staff room was observed to be locked at the time of the visit. RESTROOMS: The LPA observed 3 (three) restrooms in the facility; one is a shared restroom, one is a private restroom and one is designated for staff use. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the common resident restroom and measured 114.2 degrees Fahrenheit, which is within the required range. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room, family room, and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. Fire extinguisher was observed to be fully charged and last serviced on 05/23/2022. During today's visit a new fire extinguisher was purchased and delivered to the facility. Smoke detector and carbon monoxide detectors were tested at 02:54PM and were functional at the time of the visit. Report Continued on LIC 809-C OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage was observed locked and contained the laundry area, as well as emergency food supply, PPE supply, and storage. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. RESIDENT RECORD REVIEW: Began at 01:04PM, resident records were reviewed for documents including, but not limited to: physician's report, needs and service appraisal, and personal rights. Two (2) of five (5) resident records reviewed did indicate a TB test had been performed but results were not marked. Facility designee indicated TB tests had been administered and were negative and contacted the residents' responsible parties to obtain proof of negative TB tests. LPA will review documentation at a later date. All other records reviewed were in compliance with regulation at the time of the visit. MEDICATION REVIEW: Began at 02:05PM. Medications for 4 (four) of 6 (six) residents were observed. Prescription medications reviewed were documented and labeled in accordance with regulation. However, 3 (three) of 4 (four) over the counter medications were not labeled per regulation. INFECTION CONTROL: Not reviewed during today's visit. STAFF RECORD REVIEW: Not reviewed during today's visit. EMERGENCY DISASTER PREPAREDNESS: Not reviewed during today's visit. INTERVIEWS: Interviews will be conducted during annual continuation visit. No citations issued. Exit interview conducted. A copy of today's report was provided during the visit.the state’s words, verbatim · CDSS document, Jun 8, 2023

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility staff are not assisting resident with ADLs.

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the facility above to deliver findings. LPA Ascencio met with Staff Edna Lara at 09:50 a.m. Licensee Maricar Lee arrived at the facility at 11:15 a.m. Entrance interview conducted. On 05/24/2021, the Department received a complaint alleging that facility staff are not assisting resident with ADL’s. On 05/26/2021, LPA Ascencio and LPA Kelly Dulek conducted an interview with Licensee Maricar Lee at 11:05 a.m. Interview with Licensee revealed that there is a problem with Resident #1 (R1) and his care needs. R1 tends to call the staff every 5 – 10 minutes, during the day and night for assistance. Some of R1’s needs are to scratch their back, move R1’s leg, ask for food and change them very frequently. But, as staff are assisting R1, R1 begins to argue with staff and at times, hit staff and make them cry. Licensee added that staff have quit because of R1’s needs and behaviors. Additionally, Licensee stated that R1 requires two (2) persons assist with total care in activities of daily living (ADL). Continued on LIC 9099 - C Unsubstantiated Lastly, Licensee added that family is aware of the increased ADL’s and behavior issues of R1, and family is planning on moving R1 to another facility. A file review of R1’s medical chart, starting at 11:38 a.m., revealed that R1’s diagnosis is spastic hemiplegia affecting left side dominant, dysphagia, hypertension and requires full assistance with bathing, dressing, feeding, toiling and money management. Although, R1 is difficult and requires total care, staff continue to assist R1 in their ADL’s. Later that same day, LPAs interviewed R1 starting at 12:20 p.m. Interview with R1 revealed that most of the time, R1 must yell out for assistance. R1 stated they tend to stay in their room most of the time since it is a big hassle for staff and R1 to get up. R1 also added that some days they are not happy with the care, other days, the care is great. R1 added that the staff do come in to help but they don’t do it the way R1 likes. LPAs noted R1 has a personal cell phone in their room. R1 stated the staff help with the phone and uses the cellphone to call family, friends and the Licensee. Interviews with staff on 05/26/2021 and 01/03/2023 revealed that resident are assisted with hygiene, grooming, bathing, and eating daily. Further staff interviews revealed that two (2) residents are independent, one (1) resident needs minimal assistance with ADLs, and 2 residents need moderate assistance with ADLs such as eating, showering, transferring and toileting needs. Lastly, staff interviews revealed that staff have not refused assisting residents or have not heard of staff refusing to work with residents. Interviews on 01/03/2023 with five (5) residents starting at 11:40 a.m. revealed that the staff are very helping and take care of their wants and needs. Further interviews with residents also revealed that staff provide residents with meals, assist with toileting needs, assist with grooming and shower needs and assist with calling family or writing letters to family. During visits on 05/26/2021 and 01/03/2023, LPA observed 5 residents well groomed and taken care of with clean clothing. All residents seemed happy and expressed that their needs are being met by staff. Based on evidence gathered throughout the investigation, the allegation is unsubstantiated at this time. Exit interview conducted. Licensee stated that an email copy of the report is preferred. LPA emailed copy to the Licensee.the state’s words, verbatim · CDSS document, Jan 12, 2023 · control 29-AS-20210524100952

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 03:25 PM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with facility/agency staff Delia Casayas. Licensee Maricar Lee arrived at 03:35PM and LPA Dulek discussed the reason for the visit. The LPA, along with Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room, family room, and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. Fire extinguishers were observed to be fully charged and last serviced on 05/23/2022. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage was observed locked and contained the laundry area, as well as emergency food supply, PPE supply, and storage. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are designated for resident use and 1 (one) is designated as a staff room. The staff room was observed to be locked at the time of the visit. Report Continued on LIC 809-C RESTROOMS: The LPA observed 2 (two) restrooms in the facility; one is a shared restroom and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in both resident restrooms and both were within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. At 03:50PM, LPA observed bleach in the shared restroom under the sink and wound cleanser was observed in the unlocked restroom cabinet. INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. Staff #1 (S1) was the only staff present in in the facility upon LPA's arrival. Licensee interview revealed that S1 has been working at the facility since 06/09/2022 and was hired through an agency. LPA reviewed the facility's Guardian roster and discovered S1 does not have a criminal background clearance associated with the facility. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalties assessed in the amount of $200.00. Exit interview conducted. Todays reports, appeal rights and civil penalties were reviewed and emailed to the Licensee.the state’s words, verbatim · CDSS document, Jun 10, 2022

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kelly Dulek initiated a Case Management – Deficiencies visit for the purpose of issuing citations for concerns identified during the course of a Technical Advice visit and numerous phone conversations with the Licensee. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Maricar Lee, the facility licensee. During daily telephone conversations the week of 8/9 – 8/13/2021, as well as during a Technical Assistance visit with Ventura County Public Health (VCPH) on site at another of the Licensee's facilities and CCL joining virtually, Licensee Maricar Lee refused to re-admit Resident #1 (R1) from the hospital. Licensee stated there was insufficient staffing for R1 at the facility. CCL provided staffing resources for the Licensee, who the LPA confirmed did in fact have staff available for COVID positive residents. The Licensee indicated there was no room available for R1 at the facility; however, at the time of the Licensee’s statement, no residents were currently residing at the facility and only 4 residents were residing at another of the Licensee’s facilities, which has a licensed capacity of 6. VCPH and the hospital discharge planner indicated R1 was ready for discharge from the hospital as of 8/9/2021. As of today, the resident is still admitted to the hospital and has yet to return to the facility. The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. A telephonic exit interview was conducted. A copy of the report and appeal rights were provided via email.the state’s words, verbatim · CDSS document, Aug 16, 2021

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(22) · Plan of correction due date: Aug 16, 2021

1569.269 Enumerated rights; severability (a) Residents... have all of the following rights: (22) To be protected from involuntary transfers, discharges, and evictions... “involuntary” means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident. This requirement is not met as evidenced by: Based on interview, the Licensee transfered R1 to the hospital and refused re-admission to the facility, which poses an immediate threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2021

Plan of correction: Licensee understands she needs to readmit the resident, per the hospital's instructions.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d) · Plan of correction due date: Aug 17, 2021

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by: Based on interview and observation, the licensee/administrator was unable to provide staffing and refused to allow R1 to return to the facility upon hospital discharge, which causes an immediate safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2021

Plan of correction: Licensee has agreed to do the following: 1. Schedule a training on conduct Regulation 87405. Training must be conducted by an approved vendor. 2. Submit a letter to CCLD indicating the vendor's name, address, phone number, and date of the training. Training must be completed by 8/31/2021.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 17, 2021

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interview and observation, Licensee did not allow R1 to return to R1's room at the facility when the hospital requested discharge, which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2021

Plan of correction: Licensee has agreed to do the following: 1. Schedule a training on conduct Regulation 87468.1. Training must be conducted by an approved vendor. 2. Submit a letter to CCLD indicating the vendor's name, address, phone number, and date of the training. Training must be completed by 8/31/2021.