Enduring Oaks Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:25 a.m. The last annual conducted at this facility was on 10/18/2022. Upon arrival, there were two staff and five residents present. The Facility Manager, Tammy Frame arrived at 9:52 a.m. and at this time, the reason for the visit was explained. The Administrator, Mirvat Yacoub arrived during the inspection. Entrance interview conducted. At 9:52 a.m., the LPA along with the Facility Manager 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. KITCHEN: The LPA began the tour in the kitchen/food service area at 9:53 a.m. The hot water was measured at 106.8 degrees Fahrenheit at 9:55 a.m. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperature. There was a sufficient amount of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. Food had labels clearly marked with dates. Knives and sharps were observed locked in a drawer next to the kitchen stove. Cleaning supplies were stored under the kitchen sink locked and inaccessible. There were no pesticides or poisons observed near any food areas. LIVING ROOM/DINING ROOM: The LPA inspected the living room and dining room area. The common areas were observed to be properly furnished and relatively clean at the time of the visit. Furniture was observed to be in good condition. Fireplace was observed to be adequately screened at the time of the visit. The facility maintained a comfortable temperature. (Report Continued on LIC 809C...) (Report Continued from LIC 809...) At 10:15 a.m., the smoke detector(s) and carbon monoxide detectors were tested and operational. Fire extinguishers were observed fully charged and last serviced on 04/15/2023. The LPA observed required postings throughout the common spaces. The facility has a working telephone on premises. All doors were observed with functioning auditory alarms at the time of the visit. Entry/exits were free of obstruction. GARAGE/BACKYARD: The garage is kept locked and inaccessible at all times. Washer and dryer are located inside the garage. The LPA observed another freezer in the garage with additional food. An adequate supply of emergency food and water was observed. The LPA observed a sufficient supply of Personal Protectant Equipment (PPE). Laundry detergents and toxins were observed in the garage inaccessible to residents in care. The backyard has a covered outdoor area equipped with furniture for resident use. The LPA observed one (1) gate with a self-latching mechanism and a clear passageway in case of an emergency. There were no bodies of water noted at the time of the visit. BEDROOMS: There are four (4) resident bedrooms; two (2) single occupancy, and two (2) shared bedrooms. The LPA observed the resident bedrooms to be furnished appropriately with bedding and clean linens such as sheets, pillowcases, mattress pads, and blankets, and sufficient lighting. There is one (1) staff bedroom that is locked at all times. There is a closet in the main hallway with extra towels and linens. BATHROOMS: There are two (2) bathrooms for resident use. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The hot water was measured in each bathroom; the first bathroom measured 109.9 degrees Fahrenheit at 10:00 a.m.; and the second bathroom measured 113.5 degrees Fahrenheit at 10:13 a.m. RECORDS: Records review began at 10:18 a.m., five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) Three (3) Personnel records and Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Emergency Disaster drills were conducted within the last 6 months as per regulation; the last one conducted 09/07/2023. MEDICATIONS: Medications review began at approximately 12:25 p.m. Medications are centrally stored in a cabinet by the kitchen locked and inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No medication errors observed at this time. During today’s visit, the LPA obtained copies of the following: LIC 500 Personnel Report, LIC 9020 Resident Roster, Emergency Disaster Plan, and a copy of limited liability insurance. Exit interview conducted. No citations issued. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 19, 2023

Allegation investigated: Resident not being provided adequate care

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Administrator Mirvat Yacoub. Entrance interview. Concerns were that resident #1 (R1) is not being provided adequate care as R1’s pressure injuries are not getting better as staff have not been repositioning and changing R1 as often as needed. On 2/2/22 starting at 11:04 am interviews were conducted with staff, resident family member, and residents. Interview with staff revealed that R1 is being repositioned every 2 hours from 6 am to 10 pm. Staff sets an alarm at 2 am to turn R1. A review of R1’s records on 2/2/22 starting at 11:38 am revealed a physician’s order dated 12/29/21 stating R1’s pressure injury to R Hip was worsening. Report Continued on LIC 9099C... Substantiated Report Continued from LIC 9099... On 1/11/22 R1 had an initial evaluation with Wound Pros Wound Care Experts which recommended R1 be turned and repositioned every hour while sitting and every 2 hours while in bed as well as to keep the area clean and dry. R1’s January 2022 Re-Positioning records revealed that it was documented that R1 was only repositioned 1/1/22 to 1/9/22, 1/16/22, 1/18/22, 1/24/22 to 1/31/22 every 2 hours from 6 am to 10 pm, and was not repositioned overnight from 10pm to 6am. Re-Positioning records also indicate R1 was only repositioned 1/10/22 to 1/15/22, 1/17/22, 1/19/22 to 1/23/22 every 2 hours from 6 am to 8 pm, and was not repositioned overnight from 8pm to 6am. Based on the information obtained during the course of the investigation, the allegation that Resident not being provided adequate care is substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Feb 24, 2023 · control 29-AS-20220128151852

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 1, 2023

87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 was not being repositioned as recommended which posed a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 24, 2023

Plan of correction: Administrator has agreed to submit a Statement of Understanding explaining the steps the facility will follow to avoid similar issues from happening again regarding meeting basic care needs of the residents and submit to CCL by 03/01/2023.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:06PM. This annual had a specific emphasis on infection control practices and procedures. LPA initially met with facility staff Hilda Alvarado. Licensee Mirvat Yacoub was contacted via telephone and arrived at the facility at 12:33PM. Entrance interview conducted. 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, family room, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Garage contained the laundry area, as well as emergency food 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 for resident use and 1 (one) is designated as a staff room. RESTROOMS: The LPA observed 2 restrooms in the facility; one is a shared resident restroom and one is a private resident restroom. Resident restrooms are clean and sanitary and in operating condition with grab Report Continued on LIC 809-C bars and non-skid surfaces. Water temperature was checked in resident restrooms and at 12:37PM water in the shared resident restroom measured at 125.4 degrees Fahrenheit. INFECTION CONTROL: During today’s visit, the LPA spoke with the Consultant 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. RECORD REVIEW: Began at 12:16PM. LPA observed 2 staff working in the facility. Staff #1 (S1) indicated they have been working at the facility for over 6 months. Review of the Guardian background system revealed S1 does not have fingerprint clearance associated to 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): Exit interview conducted with Consultant/Designee Anna Fabregas. Today’s reports and appeal rights were reviewed and provided via email.the state’s words, verbatim · CDSS document, Oct 18, 2022

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Mirvat Yacoub. During initial entry screening with staff Mangacop at 10:26 am LPA observed Clorox disinfecting wipes on a table in the living room accessible to residents. During facility tour with Administrator at 10:28 am LPA observed laundry detergent, laundry sanitizer bleach, toilet bowl cleaner, wood cleaner, hardwood floor cleaner, liquid plumr, fabuloso multi purpose cleaner in an unlocked cabinet in the garage accessible to residents as the door leading into the garage was left propped open. Administrator stated that they keep the door locked when they are not in the garage. During facility tour with Administrator at 10:33 am LPA observed dish soap on kitchen counter sink and knives and scissors in a kitchen drawer that were accessible to residents. Administrator stated that they notified their maintenance person today that the lock was not working properly. A review of all resident records starting at 11:38 am revealed that all 6 residents in the facility are at risk based on their diagnosis. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview was conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Feb 2, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Feb 2, 2022

87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as knives and scissors were observed accessible to residents which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 2, 2022

Plan of correction: Administrator and staff placed knives and scissors in a locked dining room drawer during facility visit. Administrator stated that they will provide documentation staff training regarding regulation 87705(f)(1) to CCL by 2/14/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Feb 2, 2022

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed accessible to residents which posed an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Feb 2, 2022

Plan of correction: Administrator locked garage room door and placed dish soap in an inaccessible location during facility visit. Administrator stated that they will provide documentation staff training regarding regulation 87705(f)(2) to CCL by 2/14/22.