Comfort Haven for the Elderly

Type of visit: Case Management - Health Checks

On 08/22/23, Licensing Program Analyst (LPA) Talwinder Bains and Licensing Program Analyst (LPA) Sarah Benson arrived to conduct a case management and perform a health and safety check on residents in care. LPAs met with administrator Maria Medrano and explained the purpose of todays' visit. LPAs were screened by staff upon arrival including temperature. LPAs toured the facility with Administrator to check the health and safety of residents in care. Areas toured included but not limited to residents rooms, bathrooms, common areas and outside area. LPAs toured kitchen area and observed that facility has adequate food supply of 2 days perishable and 7 days non perishable per regulation. LPAs observed some residents were in common area and some are in their rooms resting after breakfast. LPAs observed that facility was clean and odor free. LPAs observed that staff were attentive to residents care needs during tour. LPAs observed residents appear to be happy and in good care during today's visit. From the tour, there was no immediate health and safety risks observed for the residents in care. The following topics were discussed: -resident supervision -food service -roles of the management -resident conditions -documentation -staffing -paper supply As a result of today’s visit, no deficiencies were observed or cited. The report was reviewed, and a copy was left at the facility.the state’s words, verbatim · CDSS document, Aug 22, 2023

Allegation investigated: Illegal Eviction

Licensing Program Analyst (LPA) Melissa Parks arrived at the facility unannounced to deliver complaint findings into the allegation listed above and met with Administrator Maria. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Illegal Eviction The facility provided a number of residents with eviction letters that were approved by the Department. As of this day Friday May 5, 2023, all eviction notices have been retracted. Therefore, the allegation is unfounded meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Maria and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents. Unfoundedthe state’s words, verbatim · CDSS document, May 5, 2023 · control 25-AS-20230221143925

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility staff do not treat resident with respect.

Licensing Program Analyst (LPA) Melissa Parks arrived at the facility unannounced to deliver complaint findings into the allegation listed above and met with Administrator Maria. Department interviewed 3 staff and 3 residents during complaint investigation on 04/24/23. Department conducted the investigation for the stated allegation from this complaint. Department conducted a tour of the facility on 04/24/23 and conducted interviews with residents and staff. Interviews indicated that all staff are treating all residents with dignity and respect. Department observed while doing facility tour on 04/24/23 that facility staff appeared to be attentive to resident’s needs and treating residents with dignity and respect. During residents’ interviews, residents stated that facility staff is treating all residents with respect and dignity and did not express any concern in this area. Based on facility tour, interviews and observation, department found out that there is no evidence that facility staff do not treat resident with respect, therefore this allegation is found to be UNFOUNDED. Exit interview conducted. A copy of this report was emailed to the Administrator. Unfoundedthe state’s words, verbatim · CDSS document, May 5, 2023 · control 25-AS-20230214132839

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Manager (LPM) Laura Munoz, LPM Lauren Crocker, Regional Manager (RM) Alycia Berryman and Licensing Program Analyst (LPA) Lavinia Muscan arrived to do a health and safety check. LPMs LPA and RM completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. The following Personal Protective Equipment (PPE) was worn: Surgical Mask. Upon arriving at the facility LPA, LPMS and RM toured the facility and met with Administrator to discuss facility's program plan and staffing regarding meeting residents needs. During todays visit the licensees were not present due to being out of town and a meeting will be requested with the licensees to discuss the current operation of the facility. No citations. Exit interview conducted.the state’s words, verbatim · CDSS document, Mar 7, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 01/30/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator/Manager- Maria Medrano and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. LPA was screened by staff upon facility entry. LPA and administrator toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: bedrooms and bathrooms for residents, common areas, dining room, kitchen area, laundry room and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being observed or cited as a result of today's inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jan 30, 2023

Type of visit: Office

On 12/14/22, around 10am, an office meeting was conducted via Microsoft Teams Platform. The purpose of this office meeting was to discuss the stipulation plan and TSP role for the facility. Present in the meeting is Regional Manager Alycia Berryman, Licensing Program Manager Laura Munoz and Troy Ordonez, Licensing Program Analyst Talwinder Bains, TSP Manager Lauren Crocker, TSP Team members Richard Gasparini and Danielle Walker-Flores, Licensees Susie Jumawan and Brian Jumawan, and Administrator/Manager Maria Medrano. The purpose of the meeting was explained to the licensees. Topics discussed during the meeting were: · Licensee/Administrator accountability for current issues with facility · Facility’s stipulation plan and progress · TSP team’s role in stipulation program The following Forms are due by 01/14/2023 and are to be submitted to TSP/RO Update facility’s plan of operation and identify the population the facility will serve. It should be noted that per Title 22 regulations, resident’s with a diagnosis of dementia and resident’s with a primary diagnosis of a mental disorder unrelated to dementia are not compatible together in a secured facility setting. The licensees shall submit the plan to TSP for departmental review. The following Forms are due by 12/15/2022 and are to be submitted to TSP/RO 60 Day Eviction (02/14/2023) notice to all residents with primary diagnosis of dementia, should the facility determine that will no longer provide Dementia care services to residents which will be identified in their updated plan of operation. Copy of this report will be e-mailed to the Licensee for Signature and a signed copy will be returned same day to LPA.the state’s words, verbatim · CDSS document, Dec 14, 2022

Type of visit: Case Management - Legal/Non-compliance

LPA Hiratsuka, conducted this quarterly probation visit. LPA met with Administrator/Manager(AM) Maria Medrano, Licensees/Administrator (L1)Susie and(L2) Brian Jumawan. LPA wore a surgical mask during this visit and observed all staff wearing masks during the visit. Today LPA toured the facility with AM upon arrival. The following topics were discussed: -resident supervision -food service -roles of the management -resident conditions -documentation -staffing LPA received a copy of most of the staff training for the month of October. There are four staff that still need training. No deficiencies cited.the state’s words, verbatim · CDSS document, Oct 27, 2022

Allegation investigated: Facility staff does not treat resident with respect. Facility staff did not safeguard resident's personal belongings.

On 9/16/2022 LPA Tryon arrived at the facility to open the complaint. LPA was screened for COVID symptoms upon arrival and termperature taken. LPA wore a mask and used hand sanitizer. LPA was able to speak with staff and 6 of 39 residents. Regarding staff treating residents with respect, all residents interviewed felt that staff is very respectful to them and other residents, and no one had issues with staff. Therefore, the allegation is UNFOUNDED. Regarding safeguarding resident's belongings this allegation was in regard to clothing items being missing. All residents interviewed said they always get their own clothes back when laundry is done. If something is missing, there is a certain place that clothes are kept so that residents can look for their lost items, and almost always can retrieve them. Staff verified that this is the case. Also, if someone has a need for certain items, the home does keep extras if needed. The allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies noted. Exit inteview conducted. Unfoundedthe state’s words, verbatim · CDSS document, Sep 16, 2022 · control 25-AS-20220915143100

Type of visit: Office

An office meeting was held on 08/10/2022 at 10:00 AM on a Microsoft Teams Meeting video conferencing system review the stipulation adopted on 07/26/2022 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period. The following were in attendance: Regional Manager Alycia Berryman, Licensing Program Manager Troy Ordonez, and Licensing Program Analyst Kerry Hiratsuka. Representing the facility are Licensees Brian and Susie Jumawan, and Administrator/Manager Maria Medrano. Alycia Berryman discussed the purpose and elements of this type of meeting. The Stipulation was reviewed with Representatives, Administrators, and Licensees who expressed their understanding. Items discussed at the meeting included, but not limited to: Stipulation contents · Findings · Revocation of License -Stayed with Probation · Limitations and conditions · Future Application for License, Registration, Certification or Approval · Licensure, Certification or Approval; Application Denial, Tolling of Probationary Period · Completion of Probation · Maintenance and Operation · General Food Service Requirements · Staffing training and requirements · Basic Services/Incidental Medical care · Technical Support Program · *Discussed the licensee’s ability to seek an early termination of probation after two years · Violation of Stipulation Term · Monitoring Fee · Department's Authority · Waiver of Hearing Rights; Waiver of Appeal/Modification Rights/Waiver of Claims · Severable terms · Public Records · Signatures · Counterparts · Effective Date: (07/26/2022) The Licensees/Respondents/Representatives stated they would abide by the following: · Abide by the contents/terms of the Stipulation (submit all documents timely) · Operate the facility in substantial compliance with the regulations and statues governing the operation of a residential care facility for the elderly. CCLD will do the following: · Increase monitoring Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. COMMENTS -LICENSE PROBATION PERIOD 07/26//2022 TO 07/26/2025 FACILITY LICENSED FOR 48 NON-AMBULATORY RESIDENTS, 06 OF WHOM MAY RECEIVE HOSPICE SERVICES.the state’s words, verbatim · CDSS document, Aug 10, 2022

Allegation investigated: Llittle availability of fruits, vegetables, either no menu or menu is not followed; No alarm system for people going in and out of the building; No activities provided to residents;

Licensing Program Analyst (LPA) Mai Thao and IB Investigator Melissa Bennett, arrived at the facility unannounced on 5/18/2022 to conduct a Complaint Investigation Visit with the above allegations and met with Susie Jumawan, Administrator. Prior to visit, LPA and IB Investigator completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA and IB Investigator ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask and surgical mask. In addition, Staff screened LPA and IB Investigator prior to entering the facility. During today's visit, LPA and IB Investigator toured the facility and delivered findings. (continue (9099-C....) Substantiated Little availability of fruits, vegetables, either no menu or menu is not followed On 1/3/2022, Licensing Program Analyst (LPA) Donna Gurriere observed that the facility did not have any fresh or canned fruit or vegetables. On 2/11/2022, 3/9/2022, and 3/15/2022, LPA Mai Thao observed the facility to have fresh and canned fruit and vegetables available. Residents who were interviewed stated that the facility have it available for them. Staff 1 (S1), stated in interviews that S1 does an inventory check in the kitchen weekly. S1 stated that groceries are done on Tuesday or Wednesday. S1 stated that staff goes shopping throughout the week if something runs out. S1 stated that sometimes an item is out of stock when the grocery is being done and staff will go out another day to get it. Administrator stated that the facility has fresh and canned fruit and vegetables all the time at the facility. LPA Thao was provided the facility’s menu. Staff 2 (S2) stated in interviews that a menu is posted outside of the Kitchen Door daily. S2 stated that they have a resident who like to pull down papers on the wall. S2 stated that the kitchen staff write down on the white board outside the kitchen door as well. Administrator and S2 stated that sometimes the facility will improvise or make something else that is different on the menu. Administrator and S2 stated that this happens occasionally because sometimes the grocery store runs out of ingredients. Staff 4 (S4) stated in interviews that there has been time when the facility ran out of fresh fruit at the facility. S4 stated that S4 notified the Licensee when they are “getting low” or out of fresh fruit. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. (Continue 9099-C....) No alarm system for people going in and out of the building. On 2/11/2022 and 3/9/2022, LPA arrived at the facility unannounced and observed that the front door auditory device was not on. S2 confirmed that the auditory system is not on. S2 stated in interviews that the auditory system is loud and some residents do not like it so the facility staff turns it off. S2 stated that the auditory system is only used if a resident has a wandering behavior and there aren’t any residents with a wandering behavior. Administrator and S2 confirmed that the facility currently has 3 residents with a diagnosis of Dementia. LPA observed that all 3 residents cannot leave the facility unassisted. In other words, 3 residents with a diagnosis of Dementia cannot leave the facility unassisted because exiting presents a hazard. S2 immediately turned on the auditory system while LPA was at the facility. On 3/15/2022, LPA arrived at the facility for different visit and the auditory device was turned on. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. No activities provided to residents; Residents stated in interviews that the facility used to have activities, but no longer have anything for the residents to do. Staff 2 (S2) stated in interviews that the facility has not have any activity due to COVID-19. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report was left at the facility. Building has bugs; On 2/11/2022 and 3/9/2022, Licensing Program Analyst (LPA) Mai Thao toured the facility and did not observe any bugs at the facility. Residents that were interviewed stated that they have not seen any bugs at the facility. Staff confirmed in interviews that the facility does not have any bugs. Administrator stated that the facility did have a bug issue, but no longer have it. Administrator stated that the facility currently has a new contract with a new pest control company. Administrator stated that the pest control company has been coming monthly to the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Resident transferred to a different facility with less than 1 week’s meds; LPA observed on facility’s Centrally Stored Medication Log for Resident 1 (R1) that R1 was admitted to the facility on 12/12/2021, with 2-week supply of medication from Skilled Nursing Facility. Staff 2 (S2) and Staff 3 (S3) stated in interviews that the facility counted R1’s medication and there was only 2 weeks’ worth of supplies. S2 and S3 stated that R1 provided S3 information on R1’s doctor and pharmacy. S3 stated that S3 called to refill the medications on 12/13/2021. S3 stated that S3 remember calling to follow up and was told that the doctor cannot approve refills because R1 has not gone to the doctor for over a year. S3 stated in interviews that S3 immediately assisted R1 in choosing a local doctor so that R1 can get prescription refills. S3 stated that the facility was able to get 1 medication refilled and staff picked it up from the pharmacy. S3 stated that S3 is not sure if R1 went to the doctor or not because R1 moved out of the facility before the appointment. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No citations were observed during this visit. An exit interview was conducted and a copy of this report was left at the facility. No place for residents to access water for drinking; Residents stated in interviews that when Residents are thirsty, they can find water to drink. Residents stated that they go to the kitchen and ask for some water to drink. Residents stated in interviews that staff always give them something to drink. Staff stated in interviews that staff offers water to residents throughout the day. Staff 2 (S2) stated that some residents buy their own sodas and juices to drink. S2 stated that the facility used to offer a water station by the activity room. S2 stated that the water station was moved because of COVID-19. S2 stated that some residents were sharing cups and the facility wanted to prevent the spread of COVID-19 and other things. Staff 1 (S1) stated in interviews that when passing medications, S1 gives residents water. S1 stated that if there are other residents around, S1 would offer them water as well. S1 stated that residents would ask S1 for water and S1 would give it to them. S1 stated that the facility goes around once per shift to give out water to all residents. S1 stated that some residents refused to drink water because they do not like going to the restroom. S1 and Staff 3 (S3) stated that they always encourage residents to drink water throughout the day. The Department found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Runned down building; On 2/11/2022, Licensing Program Analyst (LPA) Mai Thao toured the facility inside and out with Staff 2 (S2). LPA and S2 observed the facility to be clean and odorless. LPA and S2 inspected 5 resident bedroom and did not observe anything broken. All 5 rooms were clean and odorless. LPA inspected the Kitchen, Dining room, Shower Room, 2 bathroom in the hallway, and big TV room. LPA did not observe anything broken. All rooms were observed to be clean and odorless. On 3/16/2022, LPA and S2 (S2) inspected 7 random resident room and did not observe anything broken. All 7 rooms were clean and odorless. This agency has investigated the complaint alleging Runned down building. The Department found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. (Continue 9099-C.....) No evacuation plan posted; On 2/11/2022, Licensing Program Analyst (LPA) Mai Thao arrived to the facility and observed that the facility’s evacuation plan is posted outside of the medication room. Administrator and S2 stated in interviews that there is a resident who likes to tear down paper on the wall. Administrator stated that staff does their best to print another one and post it up as soon as they see that it was taken down. This agency has investigated the complaint alleging No Evacuation Plan Posted. The Department found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Physician's Report not completed upon intake for resident. Licensee Brian Jumawan stated in interviews that Resident 1 (R1) was referred to the facility through a referral agency. Licensee stated that Licensee went to the Skilled Nursing Facility to conduct a Pre-Appraisal and Assessment for R1. LPA observed that a LIC 603 PREPLACEMENT APPRAISAL INFORMATION was completed on 12/9/2021. LPA observed that R1 has a LIC 602 PHYSICIAN’S REPORT on file that was completed on 12/8/2021. LPA observed on facility records that R1 was admitted to the facility on 12/12/2021. This agency has investigated the complaint alleging Physician's Report not completed upon intake for resident. The Department found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the (Continue 9099-C....) Residents outside of the building with no supervision Staff stated in interviews that currently, the facility does not have any resident who will leave the facility unassisted. Staff 2 (S2) stated in interviews that residents who cannot leave unassisted are always accompany by a staff. S2 stated that Resident 2 (R2) is outside of the facility because R2 can leave the facility unassisted. S2 stated that there are some residents who are allowed to leave unassisted if the resident check themselves out. S2 stated R2 likes to walk, so R2 is usually found walking around the block and being outside the front of the facility. R2 stated that R2 likes to walk daily, and it keeps R2 out of trouble. LPA reviewed R2’s Physician’s Report (LIC 602) and it indicated that R2 can leave the facility unassisted. This agency has investigated the complaint alleging Residents outside of the building with no supervision. The Department found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. “This agency has investigated the complaint alleging: - No place for residents to access water for drinking; - Runned down building; - No evacuation plan posted; - Physician's Report not completed upon intake for resident; - Residents outside of the building with no supervision We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed this complaint.”the state’s words, verbatim · CDSS document, May 18, 2022 · control 25-AS-20211231120313

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: May 19, 2022

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement has not been met as evidenced by: Based on observations and interviews, Licensee did not ensure that there were at least 2 days of perishable foods at the facility, facility did not have fresh fruit. which poses an immediate health and safety or personal right risk to all residents in care.the state’s words, verbatim · CDSS document, May 18, 2022

Plan of correction: Licensee agrees to submit in a statement to Licensing stating how Licensee can ensure there is a minnumum of two days of perishable fruits and vegetables at the facility by 5/19/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: May 19, 2022

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement has not been met as evidenced by: Based on observations and interviews, Licesee did not ensure that auditory devices were on to monitor exits which poses an immediate health and safety or personal rights risk to residents with dementia in care.the state’s words, verbatim · CDSS document, May 18, 2022

Plan of correction: Licensee agrees to submit in a statement to Licensing stating how Licensee can ensure that the auditory device stays on at all times by 5/19/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: May 25, 2022

87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. Ths requirement has not been met as evidenced by: Based on interviews and observations, Licensee did not ensure that there are activities at the facility which poses a potential health and safety or personal right risks to residents in care.the state’s words, verbatim · CDSS document, May 18, 2022

Plan of correction: Licensee agrees to submit in 3 months of activity calendar to Licensing by 5/25/2022.

Allegation investigated: Resident's room is not being properly cleaned Resident's room has roaches

Licensing Program Analyst (LPA) Mai Thao and IB Investigator Melissa Bennett, arrived at the facility unannounced on 5/18/2022 to conduct a Complaint Investigation Visit with the above allegations and met with Susie Jumawan, Administrator. Prior to visit, LPA and IB Investigator completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA and IB Investigator ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask and surgical mask. In addition, Staff screened LPA and IB Investigator prior to entering the facility. During today's visit, LPA and IB Investigator toured the facility and delivered findings. (continue (9099-C....) Unsubstantiated Resident's room is not being properly cleaned On 3/16/2022, Licensing Program Analyst (LPA) Mai Thao and Staff 1 (S1) toured the facility inside and out. LPA and S1 inspected 7 resident rooms. LPA and S1 observed all 7 room to be cleaned and odorless. LPA did not observe any soiled linens or clothing in the rooms. Residents who were interviewed stated that their rooms are cleaned daily by staff. Resident stated that staff comes daily to take out the trash. Resident 1 (R1) stated that when staff are assisting resident with changing, staff takes out the dirty linens and trash immediately. R1 stated that staff does not leave it in the room. Resident 2 (R2) stated that R2’s roommate uses disposable briefs and sometimes it can cause some odor in the bathroom. R2 stated that staff immediately takes out the trash when R2 inform staff. R2 stated that staff comes by daily to take out the trash during rounds. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Resident's room has roaches On 3/16/2022, LPA and S1 toured the facility inside and out. LPA and S1 inspected 7 resident rooms. LPA and staff did not observe any roaches in the rooms inspected. Resident stated in interviews that last year the facility has roaches, but now there aren’t any. Resident stated that the facility has a pest control out monthly to inspect the facility and spray the facility. R1 stated that residents are told by staff to not store food in the room to prevent the rooms from having any roaches. R1 stated that sometimes R1’s roommate has food in the room, but R1 have not seen any roaches in R1’s room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No citations were observed. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 18, 2022 · control 25-AS-20220315150255

Allegation investigated: Resident being hit by another resident.

Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to deliver findings for the above allegation. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. In addition, Staff screened LPA prior to entering the facility. During today’s visit, LPA delivered findings. (Continue 9099-C….) Unsubstantiated Resident being hit by another resident It was alleged that Resident 1 (R1) was hit by Resident 4 (R4). R4 stated in interviews that R4 have never hit any resident before. Resident 2 (R2) stated in interviews that R2 saw R4 hit R1's arm. R1 stated that R4 slap R1 on the arm. Resident 3 (R3), Resident 5 (R5) and Resident 6 (R6) stated in interviews that they did not see R4 hit R1. R5 stated that there are a lot of arguments but never anything physical. Staff who were interviewed stated that R1 and R4 does not get along and argue with each other, but have never seen them hit each other. Staff stated that when there are any resident arguing, staff intervene immediately. Staff 1 (S1) stated in interview that S1 had to separate R1 and R4 once because they were arguing over a chair and the Television. Staff stated that staff separated the 2 residents, but did not observe hitting. Administrator stated that R1 and R4 have not gotten into any physical altercation or hit each other before. Administrator stated that residents would sometimes argue over certain things, but staff intervene quickly. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Per California Code of Regulations, Title 22, No citations were issued. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 9, 2022 · control 25-AS-20210927162256

Allegation investigated: Facility is not allowing a medical assessment to be conducted on resident in a timely manner

Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to deliver findings for the above allegation. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. In addition, Staff screened LPA prior to entering the facility. During today’s visit, LPA delivered findings. (Continue 9099-C….) Unfounded Facility is not allowing a medical assessment to be conducted on resident in a timely manner It was alleged that Licensee did not allow Resident 1 (R1) to get an updated medical assessment indicating a diagnosis of Dementia. R1 was admitted to the facility on 1/20/2021. LPA observed that facility have a medical assessment prior to R1 moving to the facility with a date of 11/06/2020. LPA observed that medical assessment indicated that R1 has dementia. LPA also observed an updated medical assessment completed on 12/30/2021 still indicating that R1 has a diagnosis of Dementia. Based on observations, interviews, and documented collected, Licensee ensured that a medical assessment was conducted timely. This agency has investigated the complaint alleging Facility is not allowing a medical assessment to be conducted on resident in a timely manner. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Per California Code of Regulations, Title 22, No citations were issued. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 9, 2022 · control 25-AS-20211026115647

Allegation investigated: Resident is not provided with hygiene items of general use

Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to deliver findings for the above allegation. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. In addition, Staff screened LPA prior to entering the facility. During today’s visit, LPA delivered findings. (Continue 9099-C….) Unfounded Resident is not provided with hygiene items of general use On 2/11/2022, Licensing Program Analyst (LPA) Mai Thao conducted a facility toured with Facility Manager (FM) and observed the facility to have sufficient hygiene products available for residents in care. Residents stated in interviews that they have their own hygiene products and when they run out, the facility always have it available. Staff stated in interviews that the facility always have hygiene products available along with other items for the residents in care. Administrator also confirms in interviews that the facility have hygiene products available for residents to use. This agency has investigated the complaint alleging Resident is not provided with hygiene items of general use. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Per California Code of Regulations, Title 22, No citations were issued. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 9, 2022 · control 25-AS-20211214084617

Allegation investigated: Staff treat residents differently Staff do not provide supplies necessary for personal care and maintenance of adequate hygiene practice

Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to deliver findings for the above allegations. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. In addition, Staff screened LPA prior to entering the facility. During today’s visit, LPA delivered findings. (Continue 9099-C….) Unfounded Staff treat residents differently Residents who were interviewed, stated that staff do not treat residents differently. Residents stated in interview that the staff does their best to meet their needs. Staff stated in interviews that staff treats all residents equally. Administrator also confirms in interviews. This agency has investigated the complaint alleging Staff treat residents differently . We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Staff do not provide supplies necessary for personal care and maintenance of adequate hygiene practice On 2/11/2022, Licensing Program Analyst (LPA) Mai Thao conducted a facility toured with Facility Manager (FM) and observed the facility to have sufficient hygiene products available for residents in care. Residents stated in interviews that they have their own hygiene products and when they run out, the facility always have it available. Staff stated in interviews that the facility always have hygiene products available along with other items for the residents in care. Administrator also confirms in interviews that the facility have hygiene products available for residents to use. This agency has investigated the complaint alleging Staff do not provide supplies necessary for personal care and maintenance of adequate hygiene practice. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Per California Code of Regulations, Title 22, No citations were issued. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 9, 2022 · control 25-AS-20211214090123

Type of visit: Required - 1 Year

On today's date around 11:00am Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Maria Medrano, Facility Manager and Susie Jumawan, Administrator and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. In addition, Staff screened LPA prior to entering the facility. LPA toured facility with Facility Manager to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathroom, bedrooms, kitchen, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Facility Manager completed the infection control domain and facility was found to be in substantial compliance at this time. During the inspection, LPA collected a copy of Administrator Certificate #6018837740, expiration date 8/1/2022 and requested for an updated LIC 500. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 11, 2022

Allegation investigated: Failed to report an incident within 7 days.

On 7/23/21 at 9:45 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with facility manager Maria Medrano and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Continuation on LIC 9099C. Substantiated Based on CCLD records and LPA Cheng records, LPA Cheng determined that the above allegation did occur. Facility provided an incident report dated 2/25/2021 and informed that they had faxed it to CCLD the same day. CCLD Chico Regional Office has no record of receiving the fax. CCLD uses an electronic system for incoming faxes. LPA Cheng was also the duty officer on 2/25/2021 and has no e-mail records of any incident reports from the facility being forwarded to the assigned LPA Mai Thao. LPA Cheng spoke to Mai Thao and was informed that the facility file in the CCLD Chico Regional Office shows no record of having the incident report dated 2/25/2021. Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of the report along with appeal rights were given.the state’s words, verbatim · CDSS document, Jul 23, 2021 · control 25-AS-20210719164036

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 2, 2021

87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by: Based on records review, Licensee did not report an incident (occurred 2/25/2021) to CCLD within 7 days which poses a potential health and safety risk to 2 of 2 clients in care.the state’s words, verbatim · CDSS document, Jul 23, 2021

Plan of correction: Licesee agreed to conduct an in-service training regarding reporting requirements and submit proof of training materials and signatures of staff participants to LPA by POC date.

Type of visit: Case Management - Health Checks

** This is an amended version of the original report delivered on 7/16/21 and replaces the original report.** On 7/16/21 at 9:15 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with facility manager Maria Medrano and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. On 7/16/21 at 9:30 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 72 degrees Fahrenheit, resident room #25 measured 71.5 degrees Fahrenheit, right hallway entrance measured 72.5 degrees Fahrenheit, room #6 measured 77 degrees Fahrenheit, and living room air vent measured 58.5 degrees Fahrenheit. Left hallway liquid thermometer measured at 68 degrees Fahrenheit, front hallway liquid thermometer measured at 72 degrees Fahrenheit, and right hallway thermometer measured at 74 degrees Fahrenheit. Residents did not express any concerns. LPA informed Medrano to monitor the temperatures and adjust the floor fans as needed. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 16, 2021

Type of visit: Case Management - Health Checks

On 7/16/21 at 3 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with facility manager Maria Medrano and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. On 7/16/21 at 3:10 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 71.5 degrees Fahrenheit, resident room #25 measured 72 degrees Fahrenheit, right hallway entrance measured 70 degrees Fahrenheit, room #6 measured 80 degrees Fahrenheit, and living room air vent measured 63.5 degrees Fahrenheit. Left hallway liquid thermometer measured at 72 degrees Fahrenheit, front hallway liquid thermometer measured at 74 degrees Fahrenheit, and right hallway thermometer measured at 78 degrees Fahrenheit. Residents did not express any concerns. LPA observed that there are no additional fans in the left wing of the facility hallways but fans were still being utilized in the right wing of the facility. LPA was informed by facility that the right wing air conditioning unit will be looked at to ensure that it's running properly. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 16, 2021

Type of visit: Case Management - Other

On 7/16/2021 at 4:30 PM, Licensing Program Analyst (LPA) Cheng was providing facility a copy of their report for his visit on 7/16/2021 between 3PM - 4:30PM and observed that LPA Cheng had inputted the incorrect date on the report. LPA reviewed previous licensing reports from 7/13/21 to 7/16/21 and observed that all dates were incorrectly given. Licensing reports from the morning of 7/13/21 to morning of 7/16/21 was amended to correct the dates originally given on the report. All copies of the amended reports were signed by Facility Manage Maria Medrano and all amended copies were provided to facility. Exit interview conducted and copy of report was given.the state’s words, verbatim · CDSS document, Jul 16, 2021

Type of visit: Case Management - Health Checks

On 7/15/21 at 4:15 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with facility manager Maria Medrano and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. On 7/15/21 at 4:30 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 81 degrees Fahrenheit, resident room #25 measured 81 degrees Fahrenheit, right hallway entrance measured 76.5 degrees Fahrenheit, room #6 measured 84.5 degrees Fahrenheit, and living room air vent measured 65 degrees Fahrenheit. Left hallway liquid thermometer measured at 76 degrees Fahrenheit, front hallway liquid thermometer measured at 76 degrees Fahrenheit, and right hallway thermometer measured at 76.5 degrees Fahrenheit. Residents did not express of any issues or concerns. LPA Cheng spoke with Alternate Administrator Brian Jumawan and was informed that they are finishing up on the installation of the new air conditioner units. Facility technician will run checks on it after an hour to ensure that it is operating correctly. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 15, 2021

Type of visit: Case Management - Health Checks

** This is an amended version of the original report delivered on 7/14/21 and replaces the original report.** On 7/14/21 at 10:45 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with facility manager Maria Medrano and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. On 7/14/21 at 11 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 75.5 degrees Fahrenheit, resident room #25 measured 70.5 degrees Fahrenheit, right hallway entrance measured 73 degrees Fahrenheit, room #6 measured 78 degrees Fahrenheit, and living room air vent measured 55.5 degrees Fahrenheit. Left hallway liquid thermometer measured at 70 degrees Fahrenheit, front hallway liquid thermometer measured at 74 degrees Fahrenheit, and right hallway thermometer measured at 76 degrees Fahrenheit. Residents did not express of any issues or concerns. Upon arrival, LPA observed that facility's sprinkler system was currently being inspected by Annual Fire and Safety. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 14, 2021

Type of visit: Case Management - Health Checks

** This is an amended version of the original report delivered on 7/13/21 and replaces the original report.** On 7/14/21 at 3 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. On 7/14/21 at 3:15 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 83 degrees Fahrenheit, resident room #25 measured 78.5 degrees Fahrenheit, right hallway entrance measured 75 degrees Fahrenheit, room #6 measured 83 degrees Fahrenheit, and living room air vent measured 67 degrees Fahrenheit. Left hallway liquid thermometer measured at 76 degrees Fahrenheit, front hallway liquid thermometer measured at 78 degrees Fahrenheit, and right hallway thermometer measured at 78 degrees Fahrenheit. Residents did not express of any issues or concerns. During LPA's visit, LPA observed that facility had acquired a crane service to replace facility Air Conditioning Units. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 14, 2021

Type of visit: Case Management - Health Checks

** This is an amended version of the original report delivered on 7/13/21 and replaces the original report.** On 7/13/21 at 11:45 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. On 7/12/21 at 12 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 73.5 degrees Fahrenheit, resident room #25 measured 67 degrees Fahrenheit, right hallway entrance measured 68 degrees Fahrenheit, room #6 measured 75 degrees Fahrenheit, and living room air vent measured 58 degrees Fahrenheit. Left hallway liquid thermometer measured at 73.5 degrees Fahrenheit, front hallway liquid thermometer measured at 74 degrees Fahrenheit, and right hallway thermometer measured at 76 degrees Fahrenheit. Residents did not express of any issues or concerns. Upon arrival, LPA observed two new air conditioning units being installed on the roof of the facility. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 13, 2021

Type of visit: Case Management - Health Checks

** This is an amended version of the original report delivered on 7/13/21 and replaces the original report.** On 7/13/21 at 4:45 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. On 7/13/21 at 4:50 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 64 degrees Fahrenheit, resident room #25 measured 54.5 degrees Fahrenheit, right hallway entrance measured 61.5 degrees Fahrenheit, room #6 measured 70 degrees Fahrenheit, and living room air vent measured 55.5 degrees Fahrenheit. Left hallway liquid thermometer measured at 76 degrees Fahrenheit, front hallway liquid thermometer measured at 80 degrees Fahrenheit, and right hallway thermometer measured at 76 degrees Fahrenheit. Residents did not express of any issues or concerns. During LPA's visit, a resident pulled the fire alarm and exited the facility. Facility fire exit protocols were followed and Marysville Fire Department responded in a timely manner. There was no threat or danger that occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 13, 2021

Type of visit: Case Management - Health Checks

On 7/12/21 at 10 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Upon arrival, LPA observed that a fire inspection was being conducted by Marysville Fire Department. On 7/12/21 at 10:15 AM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 76 degrees Fahrenheit, resident room #25 measured 73.5 degrees Fahrenheit, right hallway entrance measured 76.5 degrees Fahrenheit, room #6 measured 80.5 degrees Fahrenheit, and living room air vent measured 60 degrees Fahrenheit. Left hallway liquid thermometer measured at 76 degrees Fahrenheit, front hallway liquid thermometer measured at 76 degrees Fahrenheit, and right hallway thermometer measured at 76 degrees Fahrenheit. Residents did not express of any issues or concerns. Licensee has purchased two air conditioning units and has their technician on stand by. Facility is reaching out to local businesses who has access to a crane to lift the units onto the facility roof for installation. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Jul 12, 2021

Type of visit: Case Management - Health Checks

On 7/12/21 at 4 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. On 7/12/21 at 4:15 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 81.5 degrees Fahrenheit, resident room #25 measured 76 degrees Fahrenheit, right hallway entrance measured 75 degrees Fahrenheit, room #6 measured 81.5 degrees Fahrenheit, and living room air vent measured 60 degrees Fahrenheit. Left hallway liquid thermometer measured at 76 degrees Fahrenheit, front hallway liquid thermometer measured at 78 degrees Fahrenheit, and right hallway thermometer measured at 80 degrees Fahrenheit. Living room temperature measured at 72 degrees Fahrenheit. Residents did not express of any issues or concerns. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 12, 2021

Type of visit: Case Management - Health Checks

On 7/11/21 at 10 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. LPA toured the facility inside and out including but not limited to facility hallways, living room, facility office, resident rooms, and hallway bathrooms. On 7/11/21 at 10:15 AM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 73 degrees Fahrenheit, resident room #25 measured 73.5 degrees Fahrenheit, right hallway entrance measured 68.5 degrees Fahrenheit, room #6 measured 69 degrees Fahrenheit, and living room air vent measured 59 degrees Fahrenheit. All of facility liquid thermometers measured at 76 degrees Fahrenheit. LPA observed all 6 cooling air units purchased on 7/10/21 to be placed throughout the hallways of the facility. All residents were observed as comfortable and none mentioned any issues. No deficiency observed. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 11, 2021

Type of visit: Case Management - Health Checks

On 7/11/21 at 3 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. LPA toured the facility inside and out including but not limited to facility hallways, living room, facility office, resident rooms, and hallway bathrooms. On 7/11/21 at 3 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 68.5 degrees Fahrenheit, resident room #25 measured 61 degrees Fahrenheit, right hallway entrance measured 63 degrees Fahrenheit, room #6 measured 66 degrees Fahrenheit, and living room air vent measured 58.5 degrees Fahrenheit. All of facility liquid thermometers measured at 80 degrees Fahrenheit. LPA observed two new air conditioners at the facility; one installed in each hallway. Current temperature outside of the facility measures at 103 degrees Fahrenheit. No deficiency observed. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jul 11, 2021

Type of visit: Case Management - Health Checks

On 7/11/21 at 7 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. LPA toured the facility inside and out including but not limited to facility hallways, living room, facility office, resident rooms, and hallway bathrooms. On 7/11/21 at 7 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 87.5 degrees Fahrenheit, resident room #25 measured 88.5 degrees Fahrenheit, right hallway entrance measured 84 degrees Fahrenheit, room #6 measured 90 degrees Fahrenheit, and living room air vent measured 70 degrees Fahrenheit. Left hallway liquid thermometer measured 80 degrees Fahrenheit, front office liquid thermometer measured 82 degrees Fahrenheit, and right hallway liquid thermometer measured 84 degrees Fahrenheit. All hallway floor fans temperatures were between 80 - 86 degrees Fahrenheit. Residents did not state of any issues or concerns. LPA observed residents disabling the cooling features of two cooling units on the left hallway and one resident closing the cooling vent on one of the cooling unit in the right hallway. LPA advised staff to check cooling units frequently to ensure they are operating correctly. Exit interview conducted and copy of report was given.the state’s words, verbatim · CDSS document, Jul 11, 2021

Allegation investigated: ) Facility is in disrepair. 2) Facility has roaches. 3) COVID Protocols not followed: Screening and mask wearing.

On 7/10/21 at 1:45 PM, Licensing Program Analyst (LPA) Cheng, Singh, Johnson, and Licensing Program Manager (LPM) Munoz conducted an unannounced complaint investigations visit regarding the above allegations. LPAs and LPM met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPAs and LPM completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPAs and LPM ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Continuation on LIC 9099C. Substantiated ** This is an amended version of the original report delivered on 7/10/2021 and replaces the original report.** 1) Facility is in disrepair. Based on statements and service reports obtained on 7/9/2021, facility air conditioning unit is not working properly. Facility service reports indicate that the air conditioning blower for the backside of the facility is not working properly and requires a replacement. The service report also indicates that the air conditioning unit in the kitchen is requires a recharge of "freon". LPA Johnson and LPM Munoz observed that only 4 air vents in the facility was operational. 2) Facility has roaches. Based on observations from facility visit on 7/9/2021, LPAs Cheng and Singh observed cockroaches in resident room #17 and #16. R1 in room #16 confirmed that there were cockroaches in the resident bathrooms. LPA Singh observed cockroaches in facility kitchen areas on 7/9/2021. 3) COVID Protocols not followed: Screening and mask wearing. Based on statements obtained and document reviewed on 7/9/2021, LPAs Cheng and Singh observed that facility was not documenting staff and visitor responses to symptom screening. Facility documents show that the last documented symptom screening was dated in 5/2021. Facility was cited for failure to follow COVID protocols during LPAs Cheng and Singh visit on 7/9/2021; CCR 87468.1(a)(2). Based on LPAs and LPM information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of report was provided along with appeal rights.the state’s words, verbatim · CDSS document, Jul 10, 2021 · control 25-AS-20210710114608

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 11, 2021

87303 Maintenance and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observation and service reports obtained, Licensee did not keep the facility air conditioner in good repair and did not keep facility free of cockroaches which poses an immediate health and safety risk for all residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2021

Plan of correction: Licensee agreeed to submit to LPA an action plan regarding fixing facility's air conditioner unit and cockroach infestation via e-mail by POC date. LPA will review facility's POC and follow-up with Licensee to ensure their action plans are being enforced.