The Palms at Bonaventure Assisted Living

Type of visit: Required - 1 Year

At 08:30 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Brandy McCauley and LPA Jenny Olson arrived shortly after approximately at 9:10 a.m. At 10:12 a.m. the LPAs conducted a tour of the physical plant with Administrator Brandy to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of a memory care unit, and an assisted living unit. The LPAs observed fire extinguishers throughout the facility, which were fully charged and last serviced 01/11/2023. The Administrator provided an annual fire alarm testing and inspection report done on 10/09/2023 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPAs observed all required postings in the hallways near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: During the facility tour, the kitchen appeared clean and the appliances and fixtures functional. The LPAs observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Bedrooms: During today’s visit, the LPAs observed ten (10) randomly selected resident units. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 10:32 a.m. the LPAs observed a Monday-Sunday medication dispenser filled with vitamins/medications, and cleaning disinfectants in RM 105. At 10:57 a.m. the LPAs observed Levothyroxine Sodium and Mupirocin 2% ointment in RM220. LPAs checked both residents Physicians Report (LIC602) that indicated the residents (R1, R2) cannot manage or store their own medications. Report will continue on LIC809-C. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Out of the ten (10) bathrooms observed, two (2) toilets required cleaning, and the flooring of one (1) bathroom was unclean. Upon observation, staff cleaned the areas. Water temperature measured in the restrooms ranged between 115.3 degrees Fahrenheit and 119.3 degrees Fahrenheit. Common Areas: These included the beauty salon, library, chapel/workout room, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. Infection Control: The community's policies and procedures pertaining to infection control were adequate. Record Review: A review of facility files was initiated. LPA Olson reviewed five (5) of seventy-two (72) Staff files. Out of the five files reviewed, LPA Olson identified that two out of five staff (S1, S2) were not associated to the facility and one (1) out of five staff did not have a criminal record clearance. LPA Cortez reviewed five (5) out of ninety-three (93) resident files. All resident files reviewed were complete and accurate. MEDICATION AUDIT: A medication audit for two (2) of five (5) residents was initiated and the following was observed. The medications were stored in the medication carts, which was locked and inaccessible to the clients. During both resident audits, the LPAs observed various medications not properly documented on the centrally stored medication and destruction log, as the quantity, expiration date and refills did not match the prescription labels. In addition, various medications did not have the start date documented on the centrally stored medication and destruction log. Staff documented the correct quantity, expiration dates, start date and refills upon observation. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights providedthe state’s words, verbatim · CDSS document, Oct 18, 2023

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff handle residents in a rough manner Staff does not assist with incontinence care Insufficient staffing

At 8:40 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent complaint visit to the above facility to continue investigation of the above allegations. LPA met with Administrator Brandy McCauley and explained the purpose of the visit. LPA Rosales conducted the initial 10-day complaint visit on 05/17/2021 at 11:25 AM – 6:00 PM, the LPA reviewed resident records, obtained copies of pertinent documents and interviewed random residents. LPA Smith conducted a subsequent complaint visit on 06/13/2023 at 9:45 AM – 2:30 PM, interviewed nine (9) staff, conducted a medication audit, and interviewed four (4) residents. Today, LPA Cortez toured the facility with administrator Brandy McCauley at 10:00 am, reviewed all staff and resident interviews conducted by LPA Rosales and Smith, and interviewed two (2) staff and two (2) residents between 10:20 a.m. and 11:30 a.m. Report will continue on LIC9099-C. Unsubstantiated Staff handle residents in a rough manner. On the allegation that Staff handle residents in a rough manner, it is the concern of the reporting party that staff handle residents in a rough manner by pulling residents by their pants when transferring them, giving residents “wedges”. It was further alleged that the RP observed staff pushed a resident (R1) toward a railing when handling R1. During the initial and both subsequent complaint visits, the LPAs conducted interviews with various residents. Residents interviewed during the investigation revealed that staff treat them fine, and that “staff are very gentle and not rough”. None of the residents interviewed during the investigation voiced any concerns with staff handling them in a rough manner, with nine (9) out of eleven (11) residents stating that staff treated them fine, very well, staff are wonderful, or that they have never been handled inappropriately. In addition, R1 was interviewed during the initial complaint visit and revealed that no staff has pushed them, and that staff has never hurt or been rough with them. LPA Smith and Cortez interviewed staff during the subsequent complaint visits. Staff interviews revealed that seven (7) out of twelve (12) staff interviewed have not heard any complaints or concerns about staff handling residents in a rough manner. One out of twelve staff interviewed revealed that they had heard of staff being rough with a resident, however they did not witness it and only heard it from a peer. When asked if staff grabs on to residents clothing to transfer them staff gave mix responses, with three (3) staff stating they do not grab on the residents clothing and two (2) staff stating they do however, to guide the resident and not hurting them. Lastly staff interviews revealed that they have access to the residents’ care plans. If needed they will use a two-person assist, gait belt, hoyer lift or a sara lift machine to assist residents to transfer them. Based on the information gathered on the above allegations, although the allegations may have happened or is valid, there was insufficient evidence to confirm that Staff handle residents in a rough manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Report will continue on LIC9099-C. Insufficient Staffing and Staff does not assist with incontinence care. On the allegations that there is insufficient staffing, and that Staff does not assist with incontinence care, it is the concern of the reporting party that the facility is understaffed and that oftentimes, there are only 2 caregivers assigned to provide care for 60 residents. It was further alleged due to insufficient staffing, residents who are bedridden and residents that have dementia are left in soiled diapers for prolonged periods of time. During the initial and both subsequent complaint visits, the LPAs conducted interviews with various residents. Resident interviewed during the investigation revealed that “usually when they call staff will show up”, “that they think that they have enough staff,” and that “staff are taking care of their needs”. Resident Interviews also revealed that staff regularly check them and change their diapers, and even though there has been one time where a resident has been left soiled, it is rare. LPA Smith and Cortez interviewed staff during the subsequent complaint visits. Staff interviews revealed that residents are changed approximately every two hours or as needed. It may vary depending on the residents needs, if residents are “heavy wetters” or know they are in bed staff will check on them frequently. Staff interviews also revealed that AM staff often find residents with soiled diapers during shift change, however they are changed upon observation. Staff interviews also revealed that they are currently fully staff and will have approximately three to four caregivers per shift and a Med-Technician. It was further revealed that there are occasions where staff will call out, however the supervisor will have additional staff they can call to cover. Current weeks schedule was provided to LPA Cortez during today’s visit where it noted six (6) caregivers in assisted living (AL) and four caregivers in memory care (MC) for the 6 a.m. -2 p.m. morning shift; four (4) caregivers in AL, three caregivers in MC for the 2:00 p.m.-10:00 p.m. evening shift; and three (3) caregivers in AL, and two (2) caregivers in MC for the 10:00 p.m.-6:00 a.m. night shift. The LPA also observed six (6) on call caregivers on the facility’s schedule. Lastly, staff interviews revealed that the facility has had previous years where they were understaffed, however currently there is sufficient staffing. Based on the information gathered on the above allegations, although the allegations may have happened or is valid, there was insufficient evidence to confirm that there is Insufficient Staffing, and that Staff does not assist with incontinence care. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was provided to the administrator.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 29-AS-20210514112111

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff mishandle the residents medications while in care Staff is administering unauthorized medications to residents

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Brandy McCauley and explained the reason for the visit. On 05/24/2021, LPA’s Kelly Dulek and Martha Guzman-Chavez conducted an initial visit from 10:05 a.m. – 1:00 p.m., where they spoke with staff, conducted a tour, gathered documents, and conducted a medication audit. On 6/13/2023, LPA Smith interviewed nine (9) staff from 10:00 a.m. - 12:00 p.m., conducted a medication audit from 12:15 p.m. - 1:45 p.m., and interviewed four (4) residents from 1:50 p.m. - 2:30 p.m. Today, LPA Smith interviewed five (5) staff from 9:40 – 10:30 a.m., and interviewed three (3) residents from 10:35 a.m. – 11:20 a.m. Unsubstantiated Regarding the allegation: Staff mishandle the residents medication while in care It was alleged that staff are failing to assist residents with the self-administration of medications, and that there were many medication errors, as staff would allegedly give residents the wrong medication or an incorrect dosage. LPAs conducted a medication audit on 5/24/2021 and 6/13/2023, and the LPAs were unable to uncover evidence that the staff had failed to properly assist residents with the self-administration of medication. The Medication Administration Record (MAR) indicated that medications for the residents had been given as prescribed. The LPA also checked resident medications for expiration dates and instructions and the LPA uncovered minimal discrepancies. The LPA reviewed facility incident reports, and the LPA was unable to uncover incident reports as it related to known medication errors. Interviews revealed that staff did not recall specific occurrences where medication errors occurred, and staff claimed that when residents asked for their as-needed (PRN) medication, that staff responded. Residents did not communicate any concerns as it related to receiving their medications, and claims that they received their PRN medication once requested. Staff could not recall a time when a resident received too much medication. Based on the information from interviews, records review, and medication audits, there is insufficient evidence to support the claim that staff mishandle resident medication. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff is administering unauthorized medications to residents It was alleged that if residents requested pain medication, they would receive the house supply of Tylenol 325mg, even if the residents had a prescription for pain medication at a different strength. Staff indicated that the facility had a house supply of Tylenol and noted that it was 325mg. Staff indicated that a number of residents have an order for Tylenol as-needed (PRN), and staff noted that if the resident did not have their own medication from the pharmacy, they could use the house supply of Tylenol. The LPA conducted a medication audit for residents that had a PRN for pain medication, and records indicated that the order for pain medication was either 325mg or 650mg. Medication audit and records indicated that if the facility used the facility supply of Tylenol, residents received the appropriate dosage of pain medication as requested. Interviews from both staff and residents indicated that staff would assist residents with the self-administration of PRN medication as needed, and as prescribed by the resident’s doctor. Based on the information from interviews, records review, and medication audits, there is insufficient evidence to support the claim that staff administered unauthorized medication to residents. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 19, 2023 · control 29-AS-20210520121117

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent Case Management - Incident visit. The purpose of the visit is to conclude an investigation initiated by LPA Martha Arroyo and Esther Cortez on 03/14/2023. LPA met with administrator Brandy McCauley and explained the reason for the visit. On 03/09/2023, the Department received a Special Incident Report (SIR) regarding Resident #1 (R1). The report stated that on 03/07/2023, R1’s roommate alerted staff that R1 was on their bed bleeding from a fall. Staff observed R1 on top of their bed bleeding from the right temple area on their face. R1 was unable to recall how the incident occurred. R1’s roommate stated they were standing at the end of the bed talking when R1 turned to walk away, R1’s feet got tangled causing R1 to fall. R1 was admitted to Community Memorial Hospital for evaluation and treatment and subsequently died on 03/09/2023 of a subdural hematoma. During the initial visit on 03/14/2023, the LPA’s interviewed the Executive Director at 4:00pm and requested documents pertinent to the investigation. The incident was referred to Community Care Licensing Investigations Branch (IB) and assigned to IB Investigator Christine Ferris. Investigator Ferris conducted interviews on 03/28/2023 with residents, staff, and Memory Care Coordinator. In addition, the investigator reviewed Community Memorial Hospital medical records, facility file documents related to R1, and County of Ventura Certificate of Death. Report will continue on LIC809-C The medical records reviewed revealed that on 03/07/2023, R1 arrived at Community Memorial Hospital for an evaluation of a head injury due to a ground-level mechanical fall that occurred at 1:00 p.m. on 03/07/2023. The report states R1 experienced the fall in their bedroom at the facility. At presentation, R1 only reported severe headache. R1 also had a hematoma to the right eye, laceration above the right eye, and skin tears to the right arm, wrist, and hand. Per the Emergency Department (ED) staff, R1 was initially conversant, but became unresponsive after the computerized tomography (CT) exam. Neurosurgery was consulted and recommended to repeat imaging to evaluate for possible surgical intervention. The CT scan performed at 2:00 p.m., demonstrated a large right cerebral acute subdural hematoma measuring 2cm in thickness with right to left midline shift of 8mm. The CT scan performed at 4:00 p.m., demonstrated interval increase in size of hematoma measuring up to approximately 3.1cm in thickness and there is a right to left shift of 23mm. There was poor prognosis and no plans for surgical intervention. Per the attending physicians’ recommendations, R1 was placed on comfort measures due to R1’s advanced age, dementia, poor neurological condition, and rapidly expansive acute subdural hematoma with midline shift. On 03/09/2023 at 12:59 a.m., R1 was pronounced dead and R1’s resident representative notified. The County of Ventura Certificate of Death listed the immediate cause of death as blunt force head injury with subdural hematoma. The injury occurred due to ground level fall and was listed as an accident. Per the review of R1’s needs and services plan, R1 did not require 1 to 1 care and was able and allowed to ambulate while in their room without assistance. The fall occurred while R1 was ambulating in their own room and the witness, R1’s roommate, described the incident as accidental. Per the interviews with the staff, all were consistent saying R1 was ambulatory, independent, and used a walker on and off. When staff would bring the walker to R1 or remind R1 to use the walker, R1 would refuse to use it. Report will continue on LIC809-C Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to determine that staff failed to provide adequate supervision to R1 resulting in R1 falling in room, sustaining a subdural hematoma, and subsequently passing away at the hospital. Exit interview, copy of report given.the state’s words, verbatim · CDSS document, Jun 15, 2023

Allegation investigated: Insufficient staffing

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver the findings for the above allegations. The LPA met with Executive Director Brandy McCauley and explained the reason for the visit. On 2/08/2022, LPA Joann Rosales conducted a visit from 11:00 a.m. – 4:30 p.m., in which LPA Rosales toured the facility, interviewed staff and residents, and obtained documents. On 02/28/2022, LPA Rosales conducted a subsequent visit from 10:55 a.m. – 4:10 p.m., in which LPA Rosales interviewed random residents and staff, and obtained additional documents. The allegation of ‘insufficient staffing’ alleges that the facility was understaffed in January and February of 2022, which resulted in staff being required to work with residents although staff were positive with COVID-19. Per interviews conducted by LPA Rosales on 2/8/2022 and 2/28/2022, staff revealed that a number of staff were requested to work, despite being symptomatic and COVID-19 positive. Substantiated Per PIN 21-23, which discussed quarantine and isolation guidelines for asymptomatic and symptomatic staff, staff that are COVID-19 positive should isolate until at least 10 days have passed since symptoms first appeared. Per staff interviews of staff who were COVID-19 positive, approximately 3-5 days would pass since the onset of symptoms, and they were required to work. Despite this, staff indicated that they were still understaffed and at times, would only have one medication technician or 1-2 caregivers per shift. Staff interviews revealed that because of insufficient staffing, there were at times not enough staff to meet all caregiving needs. As a result, staff admitted that residents would not receive showers, staff were unable to fulfill laundering duties, and residents were not being checked. Interviews conducted with a private caregiver further revealed that staff were unable to respond to pendant lights timely, rooms were not cleaned regularly, and showers were not given twice a week. A review of the Daily Assignments list from February 2022 revealed that care staff were assigned approximately fifteen rooms per shift. With experienced call-offs and/or people not cleared to work, this number would increase. Whereas it was alleged that resident #1 (R1) had fallen and was on the floor for an extended period of time, there was insufficient evidence to support this claim, as staff alleged that they regularly checked residents, and staff responded to R1 when they pressed the pendant for assistance for this specific fall. If staff check on residents every 2 hours, it is unknown as to when staff checked on R1 before R1 was found on the floor. Although it was alleged that R1 claimed to have been on the floor for an hour, R1 denied this claim during an interview. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of ‘insufficient staffing’ is deemed substantiated at this time. Pursuant to Title 22 Regulations, deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's report and appeal rights were issued. An interview with the Administrator indicated that they were notified of R1 missing a ring on 1/29/2022. After searching for the ring, the staff were unable to locate R1’s property. Administrator had talked to R1’s responsible party, who indicated the possibility that R1 had misplaced one or more of the rings when R1 was hospitalized on 1/22/22. Regarding R2, R2 claimed that they had money taken from their purse in the amount of $45. R2 also stated that they did not lock their door, as staff had a key to their room. The staff who had been alleged to have taken R2’s money was interviewed, yet staff denied all allegations. Insufficient evidence was obtained from staff interviews, as staff either denied knowledge of this incident, or the staff who was accused of this incident was interviewed yet further information was not obtained. The Administrator indicated that they were ‘unsure’ of the amount of money that R2 claimed was missing. At this time, it does not appear that the facility staff failed to safeguard resident personal property. Based on the information gathered the allegation is unsubstantiated, at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 22, 2023 · control 29-AS-20220201121402

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 24, 2023

87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. 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 the facility had an inadequate number of staff to meet the residents care needs, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2023

Plan of correction: The Administrator agreed to the following: 1. Submit a Staffing Plan by 5/24/2023. Staffing Plan shall detail the efforts the licensee has employed to ensure adequate staffing in all departments in the event of a critical staff shortage.

Allegation investigated: Due to neglect, resident sustained pressure injury while in care.

Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Brandy McCauley and explained the reason for the visit. Concerns were that due to neglect, resident #1 (R1) sustained pressure injury while in care. On 06/04/2021, LPA JoAnn Rosales conducted an initial visit from 10:10 a.m. – 5:00 p.m., to which LPA Rosales toured the facility, interviewed staff and residents, and obtained pertinent documents. LPA Rosales reviewed R1’s records on 6/4/21 starting at 11:39 am. R1’s service plan dated 4/28/21 indicated R1 needed assistance with their catheter including emptying the urine bag one time per shift and as needed if it was full, keeping the tubing clean each shift and not pulling on it to prevent injury, and to notify the charge nurse or medication technician if the catheter was leaking, or if the urine was dark in color or foul smelling. Unsubstantiated Page 2 R1’s service plan also indicates they used a hospital bed with low air loss mattress to relieve pressure. The service plan indicates R1 is prone to pressure injuries due to sitting a lot and asks staff to rotate R1 as much as possible every shift and to keep bedding clean and dry. The service plan also indicates R1 wears special boots/braces to try to prevent pressure injuries on the heels and legs. On 6/4/21 starting at 2:22 pm interviews were conducted with staff and residents. Interview with staff revealed that they would reposition R1 every 2 hours, but do not document the repositioning. R1 was also regularly seen by a home health nurse and received physical therapy, hence R1 was consistently observed and monitored by appropriately skilled professionals. Records revealed that on 4/29/21 R1 was observed by Home Health Agency (HHA) nurse to have a stage 2 pressure injury on the sacral coccyx. Charting notes from 5/13/21 indicated that R1’s left buttocks was red and tender, and the nurse provided wound care treated. On 5/14/21, chart notes indicate HHA nurse instructed the staff to apply barrier cream at every brief change but to not apply gauze or a patch and leave it open. Per the HHA notes, there was no indication of neglect on behalf of staff. A review of HHA notes did not indicate that the wound appeared above a stage 2 pressure injury. HHA notes for 5/21/21 state R1 has a small sacral excoriation and informed staff to continue to use barrier cream at each diaper change. Simultaneously, chart notes on 5/15/21 indicate R1’s catheter continued to have leaking around the stoma/insertion point and notes to clean as needed to prevent breakdown. Between 5/15/2021 – 6/1/2021, due to frequent HH visits, R1’s catheter was regularly monitored. The 6/1/21 chart notes at 6:05pm indicated the HHA nurse changed the catheter and noted the catheter continues to leak around the surface area when flushing and in use by R1. According to the chart notes, the HHA nurse indicted they would notify the home health charge nurse to recommend R1 be seen by their primary care physician to address the ongoing issue of the catheter leaking. HHA notes from 6/1/21 indicate the catheter continues to drain around the tube and not through the tube. HHA notes state the recommendation for facility staff is to send out R1 for treatment if unstageable and the suprapubic catheter is not functioning properly and is draining around tubing not through. Hence, R1 was sent to the hospital on 6/1/21 due to foley catheter malfunction and returned to the facility the same day with special instructions recommending a wound care specialist. Page 3 Chart notes from 6/1/21 at 10:13pm indicate the resident was being discharged back to the facility. The ER doctor stated the catheter was functioning fine and recommended to follow up with a urologist. The facility chart notes also indicated that the ER doctor stated R1’s pressure wound was unstageable. Chart notes indicated the resident returned to the facility on 6/1/21 at 11:45pm, with no new medication or treatment orders and a diagnosis of foley catheter malfunction, but was advised to follow up with urology and wound care specialist. Charting notes indicate the HHA was informed of the wound care request. Chart notes from 6/2/21 at 1:20pm indicate a HHA nurse came to reassess R1’s pressure injury on the buttocks. The HHA nurse stated R1’s pressure injury wound was unstageable. R1 was sent to the ER again due to the prohibited health condition. Based on the information obtained during the investigation, there is insufficient evidence to support the claim that due to neglect, R1 sustained a pressure injury. R1’s care and status was regularly monitored by appropriately skilled professionals and staff kept R1’s HHA up to date regarding any changes of condition. Although R1’s catheter required attention, R1’s HHA was monitoring it and staff continued to tend to R1’s catheter within the scope of their care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 19, 2023 · control 29-AS-20210603143418

Allegation investigated: Facility did not properly manage resident's personal belongings

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent unannounced complaint visit regarding the above noted allegation. LPA met with Administrator/Executive Director Brandy McCauley, LVN and explained the reason for the visit. On 10/6/2022, the Department received this complaint alleging the facility did not properly manage resident’s personal belongings. Specifically, the allegation was Resident 1 (R1) had a bracelet stolen from their room. LPA conducted an initial complaint visit on 10/13/2022, interviewed the administrator and reviewed records. R1’s records showed they declined to have their personal items inventoried upon admission. It was also reported R1 had private caregivers during the day who stayed with R1 in their room and took R1 on errands. (continued on 9099-C) Unsubstantiated (continued from 9099) On 2/6/2023, LPA conducted another visit to the facility, met with the administrator and inspected R1’s vacant room. LPA learned that R1 had moved out of the facility. LPA then visited R1 at their new facility and spoke with one of R1’s private caregivers. LPA conducted telephone interviews with other private caregivers and R1’s responsible party. On 2/6/2023 and 2/7/2023, LPA attempted to contact two additional potential witnesses (one former staff and one former agency staff), who were on schedule before and after the bracelet was missing but attempts were unsuccessful. LPA requested a copy of the police report, but a report was not available; there have been no arrests. Based on information obtained during interviews, the Department cannot determine whether the bracelet was lost or stolen. Facility staff were not the only individuals with access to R1’s personal items as R1 also employed at least three different private caregivers. Therefore, the allegation that the facility did not properly manage resident's personal belongings is deemed Unsubstantiated at this time. Exit interview conducted and a copy of the report was emailed to the administrator.the state’s words, verbatim · CDSS document, Apr 21, 2023 · control 29-AS-20221006144842

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Martha Arroyo and Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPAs met with Executive Director, Brandy McCauley and explained the reason for the visit. Entrance interview. On 03/09/2023, the Department received a Special Incident Report regarding Resident #1 (R1). The report stated that R1’s roommate alerted staff R1 was on their bed bleeding from a fall. Staff observed R1 on top of bed bleeding from right temple area on their face. R1 was unable to recall how incident occurred. R1’s roommate stated they were standing at the end of bed talking when R1 turned to walk away, R1’s feet got tangled causing R1 to fall. During today’s visit, the LPA’s interviewed the Executive Director at 4:00pm and requested documents pertinent to the investigation. This incident was referred to Community Care Licensing Investigations Branch (IB) and assigned to IB Investigator Christine Ferris. Further investigation is required prior to issuing findings. No health and safety concerns noted at this time. Exit interview conducted. A copy of the report was issued to the Executive Director.the state’s words, verbatim · CDSS document, Mar 14, 2023

Allegation investigated: Staff are taking call pendents away from residents Staff not meeting residents incontinence needs Meals do not consist of an appropriate variety of foods

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection regarding the above allegations. The LPA met with Administrator Brandy McCauley at 10:45 AM and explained the reason for the inspection. On 03/05/2021, the complaint investigation began, although due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures the inspection was conducted virtually with the Administrator. During the visit, between 1:43 PM and 2:05 PM the LPA observed five residents rooms, rooms 124, 123, 103, 112, and 121 and the LPA requested pertinent records to be emailed. On 03/18/2022, the LPA conducted an in person inspection at the facility. During the inspection, the LPA conducted a physical plant tour with the Administrator beginning at 12:46 PM. Between 12:46 PM and 1:45 PM, the LPA observed four resident rooms in Assisted Living and four resident rooms in Memory Care. Report continued on LIC 9099-C. Unsubstantiated The LPA conducted interviews with Resident #1 (R1) at 1:00 PM, and five staff between 1:51 PM and 4:00 PM. The LPA also reviewed facility records and the kitchen menu beginning at 4:07 PM. At 5:07 PM, the LPA conducted an interview with the Administrator During today's inspection, the LPA observed the physical plant briefly and conducted interviews with seven residents and two staff members between 10:55 AM and 12:39 PM. The LPA also reviewed facility records, including the facility menu and Monthly Consultant Dietician Report. The allegation of 'Staff are taking call pendents away from residents' alleges staff were taking the pendents of resident who call for assistance too often. Interviews with residents during today's visit and during the prior visit revealed no complaints of staff taking their pendent for being used too often. Interviews with staff also revealed no knowledge of staff taking resident pendents due to excessive use. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff are taking call pendents away from residents' is deemed unsubstantiated at this time. The allegation of 'Staff not meeting residents incontinence needs' alleges staff are leaving residents in soiled diapers for a long period of time. Interviews with staff during today's inspection and during the prior inspection, revealed residents are changed at least four times a shift or as often as needed and no reports of residents being left soiled routinely from the prior shift. Interviews with residents revealed no concerns regarding staff and their assistance with activities of daily living. Based on this information, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff leave residents in soiled diapers for a long period of time' is deemed unsubstantiated at this time. The allegation of 'Meals do not consist of an appropriate variety of foods' alleges residents are served the same thing and do not receive enough variety of foods. The LPA reviewed the facility menu for the week of March 13th 2021, and for the months of January and February 2023. The LPA observed a variety of food being served each week. Menus are also reviewed by the Consultant Dietician monthly with the last report being in January 2023. Interviews with residents revealed no major issues or concerns with food and resident were generally satisfied with the menu and variety. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Meals do not consist of an appropriate variety of foods' is deemed unsubstantiated at this time. Exit interview and report reviewed. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 17, 2023 · control 29-AS-20210226084535

Allegation investigated: Staff are not assisting resident with activities of daily living Staff fail to assist residents timely with care needs Staff are failing to turn residents as needed Facility staff are not changing the bedding for residents Facility staff speaks inappropriately to staff in front of residents in care Facility staff are not following their menu plan

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection regarding the above allegations. The LPA met with Administrator Brandy McCauley at 10:45 AM and explained the reason for the inspection. On 03/05/2021, the complaint investigation began, although due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures the inspection was conducted virtually with the Administrator. During the visit, between 1:43 PM and 2:05 PM the LPA observed five residents rooms, rooms 124, 123, 103, 112, and 121 and the LPA requested pertinent records to be emailed. On 03/18/2022, the LPA conducted an in person inspection at the facility for another complaint investigation (complaint controls # 29-AS-20210226084535 and 29-AS-20200624150217) and also obtained information for this complaint investigation. Report continued on LIC 9099-C. Unsubstantiated During the inspection, the LPA conducted a physical plant tour with the Administrator beginning at 12:46 PM. Between 12:46 PM and 1:45 PM, the LPA observed four resident rooms in Assisted Living and four resident rooms in Memory Care. The LPA also conducted interviews with Resident #1 (R1) at 1:00 PM, and five staff between 1:51 PM and 4:00 PM. The LPA also reviewed facility records and the kitchen menu beginning at 4:07 PM. At 5:07 PM, the LPA conducted an interview with the Administrator. During today's inspection, the LPA observed the physical plant briefly and conducted interviews with seven residents and two staff members between 10:55 AM and 12:39 PM and with the Culinary Executive Director at 2:32 PM. The LPA also reviewed facility records, including the facility menu and Monthly Consultant Dietician Report. The allegation of 'Staff are not assisting resident with activities of daily living (ADL)' alleges staff are not assisting residents with hygiene needs. Interviews with residents revealed no issues or concerns regarding staff assistance with ADLs. Staff interviewed also revealed residents are being assisted with hygiene care. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff are not assisting resident with activities of daily living' is deemed unsubstantiated at this time. The allegation of 'Staff are failing to turn residents as needed' alleges staff are not repositioning residents as needed. Staff interviewed revealed residents are being repositioned at least every two hours when in bed or as often as needed to prevent redness or sores. Resident interviewed had no complaints regarding assistance with ADLs. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed unsubstantiated at this time. The allegation of 'Staff fail to assist residents timely with care needs' alleges staff have walked past residents when they are sliding out of their chairs and call for another staff to assist. Interviews with residents from revealed no issues or concerns regarding the timely assistance they receive from staff. Interviews. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff fail to assist residents timely with care needs' is deemed unsubstantiated at this time. Report continued on LIC 9099-C. The allegation of 'Facility staff are not changing the bedding for residents' alleges staff are not changing resident's soiled bedding. During the 03/05/2021 inspection and 03/18/2022 inspection, the LPA observed a random selection of resident rooms and did not observe soiled bedding. Interviews with residents revealed bedding is washed once a week or as needed. Interviews with staff revealed soiled bedding is washed by the caregivers as needed or weekly by housekeeping. Based on the information obtained there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Facility staff are not changing the bedding for residents' is deemed unsubstantiated at this time. The allegation of 'Facility staff speaks inappropriately to staff in front of residents in care' alleged Staff #1 (S1) yells at staff in front of residents often. Staff interviewed revealed no concerns regarding staff yelling at them. Residents interviewed had not observed any staff yelling at anyone. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Facility staff speaks inappropriately to staff in front of residents in care' is deemed unsubstantiated at this time. The allegation of 'Facility staff are not following their menu plan' alleges the facility is not following the menu. Interview with Michael Callahan, Culinary Executive Director revealed there are times the menu is not followed occasionally due to supply issues. He stated this has happened during COVID but stated the protein always stayed the same and the change may have been an item like the vegetable. Callahan was not aware of any resident complaints regarding this issue. Interviews with residents revealed no major issues or concerns with the food or menu being served. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Facility staff are not following their menu plan' is deemed unsubstantiated at this time. Exit interview conducted and report reviewed. A copy of the report and appeals rights was provided.the state’s words, verbatim · CDSS document, Feb 17, 2023 · control 29-AS-20210301124754

Type of visit: Required - 1 Year

On 10/18/22 at 9:49 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Brandy McCauley, Administrator, and explained the purpose of the visit. LPA toured the facility with the administrator and observed the following: The facility has infection control signage at the front door and signage throughout the facility on handwashing and use of masks. Cough etiquette signage was not visible, and Administrator states they recently removed signage due to deterioration. Administrator has committed to replacing the signage and will send a photo to CCL by 10/19/22. Upon entry to the facility, LPA was not screened. There is a table at the reception area with a thermometer, hand sanitizer and visitor sign-in sheet. Administrator will ensure that staff assisting visitors at the lobby are trained to screen visitors upon entry and send the training sign-in sheet to CCL by 10/19/22. Staff are wearing masks. Resident rooms have their own bathrooms with soap dispensers and paper towel dispensers. More than seven fire extinguishers are located throughout the facility. Extinguishers are fully charged and were inspected on 4/06/22. At 9:58 am, LPA observed six uncovered, unlabeled ice cream in bowls in the freezer and ten unlabeled parfait in bowls, an unlabeled container of yellow squash, and unlabeled ground meat in the refrigerator. Administrator will ensure kitchen staff are trained on proper food storage and send a copy of the training sign-in sheet to CCL by 10/25/22. The facility has a CCLD Complaint poster, however, it is an 8.5”x11”. Regulation is a 20”x26” complaint poster. Administrator will post a regulation size poster and send a photo to CCL by 10/25/22. At 10:43 am, LPA observed two areas of the facility’s fence that were damaged due to fallen trees. Administrator has committed to replacing the fences and will send the estimate(s) for repair to CCL by 10/25/22. At 10:57 am, LPA conducted the Infection Control mitigation module with the licensee. No deficiencies cited. Exit interview conducted and report emailed to the administrator.the state’s words, verbatim · CDSS document, Oct 18, 2022

Allegation investigated: Staff did not properly transfer resident resulting in a fall

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today. The LPA met with Administrator Brandy McCauley at 12:41 PM and explained the reason for today's visit. During the previous virtual inspection on 07/01/2020, at approximately 11:40 AM, LPA conducted a physical plant tour of the facility utilizing a video call with Ms. McCauley. The LPA observed five resident rooms in Assisted Living and five resident rooms in the Memory Care unit. The LPA also met with five residents in the memory care unit and conducted brief interviews. During today's inspection, the LPA conducted a physical plant tour with the Administrator beginning at 1:46 PM. Between 12:46 PM and 1:45 PM, the LPA observed four resident rooms in Assisted Living and four resident rooms in Memory Care. The LPA also conducted interviews with Resident #1 (R1) at 1:00 PM, and five staff between 1:51 PM and 4:00 PM. The LPA reviewed facility records beginning at 4:07 PM. At 5:07 PM the LPA conducted an interview with the Administrator. Report continued on LIC 9099-C. Substantiated The allegation of 'Staff did not properly transfer resident resulting in a fall' alleged Resident #2 (R2) who is a two person assist with use of a mechanical lift, fell from their wheelchair due to Staff #1 (S1) assisting R2 alone and not properly setting R2 on the wheelchair using the lift. Record review revealed, in the March 31, 2020 service plan, states that two staff must be present during all mechanical lifts for all transfers for R2. Interviews revealed R2 sustained a fall when S1 transferred R2 using the lift without assistance from another staff as indicated in the service plan. Record review revealed R2 had a witnessed fall on 06/22/2020 when staff was trying to readjust the resident in their wheelchair and the resident slipped out. No injuries were noted. It is noted to use the hoyer lift and two person assist when getting the resident back into the wheelchair. Based on the information obtained, there is sufficient evidence to support the allegation occurred, therefore the above allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, and report reviewed with the Administrator. A copy of this report and appeal rights will be issued. The allegation of 'Residents are not being provided clean linen' alleges staff does not change resident's soiled linens. During today's inspection, and during the previous inspection, the LPA observed 18 resident rooms and observed clean linens and bedding in each room. Interviews with R1 and staff today, indicated no history of residents having soiled linens. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegation of 'Residents are not being provided clean linen' is deemed unsubstantiated at this time. The allegation of 'Resident was left on the floor for an extended period of time' alleges Resident #3 (R3) was left on the floor for hours after a fall. Interviews and record review revealed although R3 had documented falls near the end of their life, there is no evidence to support the allegation occurred. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegation of 'Resident was left on the floor for an extended period of time' is deemed unsubstantiated at this time. The allegations of 'Staff hit resident' and 'Residents are not properly bathed' alleged two unknown staff used dish soap and paper towels when showering R4 and one of these two staff hit R4 on the back when showering R4. Interviews revealed no knowledge of staff using dish soap or paper towels when showering R4 and no knowledge of any staff hitting R4. R4 has since passed away. When conducting the physical plant tour, the LPA observed body wash and other hygiene items in each resident bathroom. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegations of 'Staff hit resident' and 'Residents are not properly bathed' is deemed unsubstantiated at this time. The allegation of 'Staff handles resident in a rough manner' alleged Staff #2 (S2) pulled the arm of Resident #5 (R5) while R5 was being changed. S2 no longer works for the facility due to unrelated reasons. Interviews revealed no history of S2 being rough with any residents. The last name of R5 was not provided with the complaint so it is unclear who R5 may be. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegations of 'Staff handles resident in a rough manner' is deemed unsubstantiated at this time. Report continued on LIC 9099-C The allegation of 'Resident sustained an unexplained injury while in care' alleged Resident #6 had an unexplained injury of two swollen fingers. The complainant only provided a first name for R6 who resided in the memory care. During the initial inspection on 07/01/2020, the LPA virtually met with two residents with the same name as R6. The LPA was unable to interview them due to their impairments. The Administrator was not aware of any injuries to either resident at the time. Interviews today revealed no history of injuries of the hand to any residents with R6's name. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegations of 'Resident sustained an unexplained injury while in care' is deemed unsubstantiated at this time. Exit interview and report reviewed with Administrator. A copy of the report and appeal rights will be issued.the state’s words, verbatim · CDSS document, Mar 18, 2022 · control 29-AS-20200624150217

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 31, 2022

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 interviews and record review , the licensee failed to comply with the section cited above as R2 sustained a fall as a result of S1 not following R2's service plan when lifting R2 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2022

Plan of correction: The Administrator shall ensure all staff, have training regarding the use of a mechanical lift/tranfer training and reviewing serivces plans and submit proof to CCL by 3/31/2022.

Allegation investigated: Residents are not provided clean linens

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today. The LPA met with Administrator Brandy McCauley at 12:41 PM and explained the reason for today's visit. During the previous virtual inspection on 03/05/2021, an interview was conducted with the Administrator. At 1:43 PM a virtual inspection via FaceTime was conducted. Between 1:43 PM and 2:05 PM the LPA observed five residents rooms, rooms 124, 123, 103, 112, and 121. During today's inspection, the LPA conducted a physical plant tour with the Administrator beginning at 12:46 PM. Between 12:46 PM and 1:45 PM, the LPA observed four resident rooms in Assisted Living and four resident rooms in Memory Care. The LPA also conducted interviews Resident #1 (R1) at 1:00 PM, and five staff between 1:51 PM and 4:00 PM. The LPA reviewed facility records beginning at 4:07 PM. At 5:07 PM, the LPA conducted an interview with the Administrator. Report continued on LIC 9099-C. Unsubstantiated The allegation of 'Residents are not being provided clean linen' alleges resident linens are dirty and stained. During today's inspection, and during the previous inspection, the LPA observed 13 resident rooms and observed clean, unstained linens and bedding in each room. Interviews with R1 and staff today, revealed no history of residents having soiled linens. Based on the information obtained, there is insufficient evidence to support the allegation occurred, therefore the allegation of 'Residents are not being provided clean linen' is deemed unsubstantiated at this time. Exit interview and report reviewed with the Administrator. A copy of the report will be issued.the state’s words, verbatim · CDSS document, Mar 18, 2022 · control 29-AS-20210226084535

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.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Case Management - Incident visit at the facility today to follow up on an incident report pertaining resident #1 (R1). On 2/12/22 R1 was observed at The Bonaventure Independent Living facility which is next door to the facility. Staff #1 (S1) went to the facility next door and escorted R1 back to the facility. R1 did not sustain any injuries related to the incident. R1's family member was notified and and agreed to move R1 to memory care due to R1's confusion and elopement risk. During today's visit LPA toured the facility with the Administrator. Administrator stated that R1 was last seen in the dining room for dinner on 2/12/22. Administrator stated that during the weekends they do not have anyone at the front desk. Administrator stated that R1 was moved into memory care the evening of the incident on 2/12/22. Based on interviews and a review of R1's records on 2/25/22 at 1:00 pm LPA observed that R1 is not able to leave the facility unassisted. During facility tour on 2/28/22 starting at 11:01 AM with Administrator Brandy McCauley LPA observed that staff #1 (S1), S2 and S3 are working at the facility and are fingerprint cleared and not associated to the facility. Administrator stated that S1 started working with residents today. S2 worked at the facility on 2/7, 2/8, 2/9, 2/10, 2/14, 2/15, 2/16, 2/17, 2/19, 2/20, 2/21, 2/22, 2/23, 2/27 and 2/28/22. S3 worked at the facility on 2/1, 2/2, 2/3, 2/4, 2/6, 2/7, 2/10, 2/11, 2/12, 2/13, 2/14, 2/15, 2/17, 2/18, 2/22, 2/23, 2/24, 2/25, 2/26 and 2/28/22. Administrator stated that S2 and S3 are not their staff and that they work for a Home Care Agency named Genie Home Care Staffing Agency. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Continued on 809C Civil penalties assessed in the amount of $3,600.00. Exit interview conducted, today's reports, appeal rights and civil penalty were reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Feb 28, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(c) · Plan of correction due date: Feb 28, 2022

87464 Basic services (f)(1)(c) Basic services shall at a minimum include: Care and supervision as defined… Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living… 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 left the facility unassisted which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 28, 2022

Plan of correction: R1 was placed on alert charting and Service Plan was updated. R1 was moved into the memory care on 2/12/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Feb 28, 2022

87355 Criminal Record Clearance. (e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c) or... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1, S2 and S3 were associated prior to allowing S1, S2 and S3 to work which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 28, 2022

Plan of correction: S1, S2 and S3 require to obtain criminal transfers. Administrator will submit copies of criminal background clearance transfer request, LIC508 and photo identifications to CCL by 2/28/22. Administrator stated that they will not employ staff unless they are associated with the facility.

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 Brandy McCauley. During facility tour with Administrator at 11:15 am LPA observed Fabric Conditioner, Enviro-Coil cleaner, Oasis Multi-Quat Sanitizer/Disinfectant/Deodorizer, Oasis Orange Force Multi-Surface Cleanser in 1st floor Laundry Room accessible to residents. During facility tour with Administrator at 11:21 am LPA observed Apple Cinnamon Diffuser refill and Concentrated Laundry Fresh Air Freshener in Memory Care kitchen accessible to residents. At 11:50 am LPA observed a lighter in back area patio accessible to residents. 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 Penalty assessed in the amount of $250.00. Exit interview was conducted, today's reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Feb 8, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Feb 18, 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 a lighter was observed accessible to residents which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 8, 2022

Plan of correction: Administrator disposed of the lighter during the facility visit. Administrator stated that they will provide documentation staff training regarding regulation 87705(f)(1) to CCL by 2/18/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Feb 9, 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 8, 2022

Plan of correction: Administrator locked laundry room door and staff placed Apple Cinnamon Diffuser refill and Concentrated Laundry Fresh Air Freshener in an inaccessible location during facility visit. Administrator stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 2/10/22.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 12:51 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Brandy McCauley and discussed the reason for the visit. Entrance interview conducted. The LPA, along with the Admin toured the physical plant areas inside and outside at 1:20 p.m. to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 104 total bedrooms; 72 (seventy-two) are in assisted living and 28 (twenty-eight) are in memory care; with 16 (sixteen) shared and 12 (twelve) private apartments there. RESTROOMS: Public and resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. Continued on LIC 809 - C The courtyard has a covered outdoor area equipped with furniture, that was in good repair, for resident use. There were no bodies of water noted. LPA observed different locked storage rooms which contained emergency food supply. Medication room was observed to be locked containing resident files and at least 30 (thirty) days worth of medication supply for residents. KITCHEN: Kitchen appliances were 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. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices around 1:00 p.m. There is only 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. Per PIN, facility is obtaining a copy of the vaccination card or require a 72 (seventy-two) hour COVID-19 test to be taken for visitation. The LPA observed at least a 30 (thirty) day supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility has had a confirmed case of COVID-19. 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 does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate. The following recommendations were made: - Post PINs and educate staff, residents, and families on changing policies and procedures from the Department No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via email to the administrator.the state’s words, verbatim · CDSS document, Oct 8, 2021