Villa Board and Care Home

Type of visit: Office

An Informal Conference was held on 4/14/2022 at 2:00pm, via remote. The informal conference process was explained to the Administrator. The Administrator was also informed that this Informal Conference is part of the administrative action process and that further citations will result in a formal Non-Compliance Plan, and may lead to a referral to the Department's Legal Division for a possible Administrative action. Present during the meeting were Licensing Program Manager (LPM) Jeremy Fong, LPM Harpreet Humpal, Licensing Program Analyst (LPA) Carol Fowler, LPA Laura Hall, Administrator Daniel Villa. The purpose of today's Informal Conference was to discuss the recent deficiency at the Administrators facility from a annual visit 2/17/2022. LPM J. Fong, LPM H. Humpal, LPA C. Fowler and LPA L. Hall discussed the following issue: -Accepting a bedridden resident with a restricted condition without an exception. -Staff training for a resident with a restricted condition. -Incomplete resident file. -Providing a care plan for the resident. During the meeting, the licensee agree to submit proof of the following by April 18, 2022: - A formal letter requesting an exemption. - A letter from the residents family. -A care plan. The following deficiency was issued for administrators qualifications (see LIC 809D) administrator failed to submit an exception request for the resident with a restricted health condition before accepting resident into the facility. (cont 809-C) Civil Penalty continues as the licensee has failed to submit requested documents Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 14, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a)(d) · Plan of correction due date: Apr 18, 2022

(a) All facilities shall have a qualified and currently certified administrator...freedom from other responsibilities and shall be on the premises a sufficient number of hours ... there shall be coverage... (d) The administrator shall have the ...Sections 87405(d)(1) through (7). .... This requirement was not met as evidence by: Based on LPA's observation licensee did not comply with the section cited ablove which poses and immediate helath and safety risk to clients.the state’s words, verbatim · CDSS document, Apr 14, 2022

Plan of correction: Administrator agreed to provide CCLD with a detail plan of what needs to be done when accepting a resident with a prohibited condition and have CCLD approve the plan.

Type of visit: POC

On 03/30/2022 at 2:55pm, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct a proof of correction (POC) visit for the deficiencies cited on 3/22/2022.. LPAs met with Administrator, Daniel Villa and explained the purpose of the visit. On today's date LPA observed ceiling had been repaired in the bathroom for CCR 87303(a) and garage no longer occupied staff using it as a sleeping room 87208(a)(7). These two (2) deficiency are cleared. Administrator did not submit POC for 87621(b)(1)(B). A civil penalty has been assessed from 3/22/2022 to 3/30/2022 at $100 x 9 = $900. LPAs printed out regulations 87621 and 87616 for Administrator to review and submit correct documents. Plan and proof of correction was discussed with Administrator. Civil Penalties will continue to be assessed daily until corrected. No deficiencies are being cited on this date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 30, 2022

Type of visit: POC

On 03/22/2022 at 1:20 pm, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct a POC visit. LPAs met with Administrator, Daniel Villa and explained the purpose of the visit. Upon arrival LPAs had not received any POCs from Administrator. Administrator requested for extension on 3/11/2022 submission of POC for deficiencies cited from annual inspection date 3/03/2022. The POC due dates were 3/11/2022 with the exception of section #87705(f)(1) with the due date of 3/5/2022. The proof of corrections for deficiencies section #87705(f)(1) and 87211(a)(1) were cleared during POC visit. Administrator requested extension due to a fall. LPA C. Fowler extended the request until 3/15/2022 with the exception of sections 87621(b)(1)(B) and 87606(f)(1). On this same day, LPA C. Fowler discussed with Administrator the above and informed him that LPA C. Fowler will recite. An immediate Civil penalty of $500 was issued today. Deficiency section 87606(f)(1) is re-cited--refer to LIC809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Plan and proof of correction was discussed with Administrator. Exit interview conducted. Appeal Rights and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 22, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87606(f)(1) · Plan of correction due date: Mar 23, 2022

87606(f)(1) (f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by accepting a bedridden resident with restricted health condition without fire clearance in room #1. Which poses an immediate health and safety risk to clients.the state’s words, verbatim · CDSS document, Mar 22, 2022

Plan of correction: Administrator agreed to apply for a fire clearance and update the facilities Plan of Operation and provide a copy to CCLD by the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87621(b)(1)(B) · Plan of correction due date: Mar 23, 2022

87621(b) In addition to Section 87611 the licensees shall be responsible... (1) Ensuring that ostomy care is provided by an appropriately...(B)There shall be written documentation by an appropriately skilled professional outlining...instruction...facility staff who have been instructed. This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by accepting a bedridden resident with restricted health condition without fire clearance in room #1. Which poses an immediate health and safety risk to clients.the state’s words, verbatim · CDSS document, Mar 22, 2022

Plan of correction: Administrator agreed to apply for a fire clearance and update the facilities Plan of Operation and provide a copy to CCLD by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(17)(A)(B) · Plan of correction due date: Mar 29, 2022

87506(b) Each resident’s record shall contain at least the following ...(17)Documents and information required...(A)Section 87457, Pre-Admission Appraisal;(B)Section 87459, Functional Capabilities;(C) Section 87461, Mental Condition; (D)Section 87462, Social Factors This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by missing required documentation in residents files, Pre-placement Appraisal Needs and Services Plan, Identification and Emergency Information, Consent for Medical Treatment and Residents Rights. Which poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 22, 2022

Plan of correction: Administrator agreed to provide a copy of the Mitigation Plan to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Mar 29, 2022

87303 Maintenance and Operation (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 evidence by: Based on LPAs observation licensee did not comply with the section cited above by not providing a grab bar in the bathtub. having a hole in the ceiling from an upstairs bathroom leak in the shared bathroom. Using a screwdriver to operate the shower faucet in bedroom #1. Which poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 22, 2022

Plan of correction: Administrator agreed not to allow staff to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(A)(7) · Plan of correction due date: Mar 29, 2022

87208((A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following: This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by staff sleeping in the garage in a makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 22, 2022

Plan of correction: Administrator agreed not to allow staff to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC date.

Type of visit: Case Management - Annual Continuation

On 3/4/2022 at 10:15 am Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver the findings from the Infection Control Inspection conducted on 3/1/2022 LPA met with Administrator, Daniel Villa and explained the purpose of the visit. LPAs observed the following deficiencies; -At 2:40pm LPAs observed facility dose not have a Mitigation Plan. -At 2:49pm LPAs observed unlocked scissors on desk in office/dining room. -At 2:50pm LPAs observed rakes, shovel, paint, tree trimmer, 3 ladders, lawn mower and unlocked shed in back yard. -At 2:59pm LPA's observed a hole in the ceiling, no grab bar in bathtub, in shared bathroom, water temperature 129.5 degrees F. -At 3:04pm LPAs observed bedridden resident with restricted health condition without fire clearance in room #1. -At 3:05pm LPAs observed a screw driver in the shower to operate the shower faucet in bedroom #1. -At 3:11pm LPAs observed garage door unlocked. In the garage there was a staff sleeping in a makeshift bedroom being used for accommodation. Continued on LIC809C. Continued from LIC809 -At 3:16 pm during record review LPAs observed R1 file was missing Preplacement Appraisal Needs and Services Plan, Identification and Emergency Information, Consent for Medical Treatment and Residents Rights. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 4, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Mar 11, 2022

87303 (e) Water...shall be maintained as follows:(2) Faucets used by residents for personal care...Hot water temperature controls shall be maintained... temperature of not less than 105 degree F (41 degree C) and not more than 120 degree...This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by maintaining water temperature between 105 degree F and 120 degree F which poses an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator agreed to adjust temperature to measure between 105 - 120 degrees F. and submit a photo copy of temperature to CCLD by POC date. Deficiency cleared during visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(1) · Plan of correction due date: Mar 5, 2022

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)..This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by not maintaining a safe environment with unlocked rakes, shovel, paint, tree trimmer, 3 ladders, lawn mower and unlocked shed located in the back yard. which poses an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator agreed to turn the garage doorknob around to lock from the outside. To move tools into the locked garage. To purchase a new lock for the shed and submit photo copies to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87621(b)(1)(B) · Plan of correction due date: Mar 11, 2022

87621(b) In addition to Section 87611 the licensees shall be responsible... (1) Ensuring that ostomy care is provided by an appropriately...(B)There shall be written documentation by an appropriately skilled professional outlining...instruction...facility staff who have been instructed. This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by accepting a resident with a restricted health condition. Which poses an immediate health and safety risk to clients.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator agreed to obtain training for staff from an appropriately skill professional and apply for a waver from CCLD, and provide copies to CCLD by the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87606(f)(1) · Plan of correction due date: Mar 11, 2022

87606(f)(1) (f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by accepting a bedridden resident with restricted health condition without fire clearance in room #1. Which poses an immediate health and safety risk to clients.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator agreed to apply for a fire clearance and update the facilities Plan of Operation and provide a copy to CCLD by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 11, 2022

87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, ... (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,,, This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by not having a Mitigation Plan LIC 808. Which poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator agreed to provide a copy of the Mitigation Plan to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b)(17)(A)(B) · Plan of correction due date: Mar 11, 2022

87506(b) Each resident’s record shall contain at least the following ...(17)Documents and information required...(A)Section 87457, Pre-Admission Appraisal;(B)Section 87459, Functional Capabilities;(C) Section 87461, Mental Condition; (D)Section 87462, Social Factors This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by missing required documentation in residents files, Pre-placement Appraisal Needs and Services Plan, Identification and Emergency Information, Consent for Medical Treatment and Residents Rights. Which poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator agreed to complete the resident file and send a copy to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 11, 2022

87303 Maintenance and Operation (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 evidence by: Based on LPAs observation licensee did not comply with the section cited above by not providing a grab bar in the bathtub. having a hole in the ceiling from an upstairs bathroom leak in the shared bathroom. Using a screwdriver to operate the shower faucet in bedroom #1. Which poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator agreed to install a grab bar in the bathtub, to get the hole in the ceiling fixed and provide pictures and a copy of the invoice to CCLD by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87208(A)(7) · Plan of correction due date: Mar 11, 2022

87208((A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following: This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by staff sleeping in the garage in a makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator agreed not to allow staff to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 156.72 · Plan of correction due date: Mar 11, 2022

87212 Emergency Disaster Plan (a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by not having an Emergency Disaster Plan. Which poses a potential health and safety risk to residents. which poses a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator agreed to provide a copy of the facilities Emergency Disaster Plan to CCLD by POC date.

Type of visit: Required - 1 Year

On 03/01/2022 at 2:30pm Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Daniel Villa and explained the purpose of the visit. Upon entry, LPAs temperature was not checked. LPA observed screening station that contained hand sanitizer and thermometer . LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. Smoke detector/carbon monoxide was in operation condition. First aid kit was complete. LPAs will return and continue the infection control inspection at a later date. Exit interview conducted and a copy of this report provided. .the state’s words, verbatim · CDSS document, Mar 1, 2022