Hailey's Care Home

Type of visit: Required - 1 Year

On 07/27/23 around 01:10 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA contacted Maria Riformo (ADM) and explained the purpose of the visit. Matthew Riformo, Administrator (ADM) arrived about 10 minutes later to assist with the inspection. ADM currently holds a standard certificate (#6045022740). The facility’s fire clearance was approved for six (6), no more than four (4) non-ambulatory residents and one (1) bedridden. Upon entry, LPA and ADM toured the facility including, but not limited to common areas, bathroom, bedrooms, kitchen, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. The facility has an updated Infection Control Plan (ICP). All hand washing stations were equipped with soap, paper towels and covered garbage cans. There is a surplus of PPE centrally located inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 106.5 degrees Fahrenheit (F) and the facility's temperature was comfortable. Fire extinguisher was observed full. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete. continued on LIC809C... ...continued from LIC809. LPA reviewed two (2) complete staff records. There are not any residents at this time. The following forms are to be updated and submitted to CCLD: -LIC500 Personnel Report (Reviewed) -LIC308 Designation of Administrative Responsibility (Reviewed) -LIC610E Emergency Disaster Plan (Reviewed) -An updated copy of Administrator Certificate(s) Exit interview conducted and a copy of this report provided to ADM.the state’s words, verbatim · CDSS document, Jul 27, 2023

Allegation investigated: Staff did not provide residents with proper notification of facility closure due to COVID-19. Staff did not provide responsible party with resident's service plan. Staff did not provide residents with a list referral agencies. Licensee did not provide residents with contact information for CCL/LTCO to file complaints.

On 5/3/2023 at around 9:30AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. LPA met Administrator Maria Riformo, LPA informed her the purpose of the visit. LPA observed zero residents during the visit. Based on interview and records review, Licensee failed to issue a proper eviction letter with complete information according to health and safety code section 1569.682 to residents or to residents’ representative. Records review revealed that on 01/18/2022 an eviction letter was generated and provided to residents and residents representative; however, the eviction notice was incomplete, the letter was missing the following information: resident's service plan, list referral agencies, contact information for CCL/LTCO to file complaints. Based on the eviction notification the residents and representative were not given 60-days before the intended eviction. ...CONTINUE TO LIC9099C... Substantiated The preponderance of evidence has been met. Therefore, the allegations above are substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, May 3, 2023 · control 15-AS-20220127120314

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.682(a)(2) · Plan of correction due date: May 12, 2023

“(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility....(2) Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction. This requirement was not met as evidence by: Based on interview and records review, licensee failed to provide proper notification to residents in care which poses a potential risk to the health and safety of resident under care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Administrator agreed to submit a self-certification to CCL stating that she will review and follow the health and safety code cited. On 1/26/2022 The facility issued a new eviction letter to comply with the eviction procedure.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.682(a)(2)(B) · Plan of correction due date: May 12, 2023

(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility....(2) Provide each resident or the resident’s responsible person with a written notice..B) A copy of the resident’s current service plan This requirement was not met as evidence by: Based on interview and records review, licensee failed to provide proper eviction notification with a copy of the resident’s current service plan which poses a potential risk to the health and safety of resident under care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Administrator agreed to submit a self-certification to CCL stating that she will review and follow the health and safety code cited. On 1/26/2022 The facility issued a new eviction letter to comply with the eviction procedure.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.682(a)(2)(D) · Plan of correction due date: May 12, 2023

(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility....(2) Provide each resident or the resident’s responsible person with a written notice...(D) A list of referral agencies. This requirement was not met as evidence by: Based on interview and records review, licensee failed to provide proper eviction notification with list of referral agencies which poses a potential risk to the health and safety of resident under care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Administrator agreed to submit a self-certification to CCL stating that she will review and follow the health and safety code cited. On 1/26/2022 The facility issued a new eviction letter to comply with the eviction procedure.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.682(a)(2)(F) · Plan of correction due date: May 12, 2023

(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility....(2) Provide each resident or the resident’s responsible person with a written notice..(F) The contact information for the local long-term care ombudsman... This requirement was not met as evidence by: Based on interview and records review, licensee failed to provide proper eviction notification with contact information for CCL/LTCO to file complaints which poses a potential risk to the health and safety of resident under care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Administrator agreed to submit a self-certification to CCL stating that she will review and follow the health and safety code cited. On 1/26/2022 The facility issued a new eviction letter to comply with the eviction procedure.

Type of visit: Required - 1 Year

On 07/14/2022 at 3:20 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Licensee Maria Riformo and Administrator Matthew Riformo (ADM). LPA explained the purpose of the visit. Facility has a COVID-19 mitigation plan on file. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, masks, face shields, gowns, gloves, COVID-19 signage, and a visitor sign-in log. LPA toured the facility including, but not limited to common areas, bathroom, and kitchen. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. Licensee to post 20 seconds to hand washing sign in the bathroom, and create an isolation cart for infection control. There was a sufficient supply of non-perishable foods; there are not any residents at this time. All hand washing stations were equipped with soap, paper towels, and covered garbage cans . There is a surplus of PPE centrally stored inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 109 degrees Fahrenheit (F). Fire extinguisher was observed full. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete. Licensee, Maria Riformo agreed to inspect, disinfect facility and notify, CCLD prior to accepting new residents. The following forms are to be kept updated and submitted to CCLD: -LIC500 Personnel Report (Reviewed) -LIC308 Designation of Administrative Responsibility (Reviewed) -LIC610E Emergency Disaster Plan (Reviewed) -An updated copy of Administrator Certificate(s) (Reviewed) Exit interview conducted and a copy of this report provided to Licensee, Maria Riformothe state’s words, verbatim · CDSS document, Jul 14, 2022

Type of visit: Case Management - Other

On 05/12/22 at 09:25 AM, Licensing Program Analyst (LPA) L. Holmes conducted an announced case management visit to amend complaint (15-AS-20220328152756). LPA explained the purpose of the visit with Maria Riformo, Administrator (ADM), which is to capture signatures of LPA and ADM. LPA obtained signatures for the LIC9099-D and LIC9099-C Exit interview conducted and a copy of the amended report was given to the Administrator.the state’s words, verbatim · CDSS document, May 12, 2022

Allegation investigated: Illegal eviction

On 04/04/2022 at 9:25 AM Licensing Program Analyst (LPA) L. Holmes arrived announced to follow-up on an unannounced complaint visit from 04/01/2022 when LPA was informed by Licensee that the facility did not have any residents. LPA met with Licensee, Maria Riformo and Administrator, Matthew Riformo and explained the purpose of the visit. During the course of investigation, LPA and Licensee discussed 3 residents, collected documents including but not limited to Admissions Agreement, ID/Emergency information and Preplacement Apprailsal Information. At 9:35 AM LPA asked Licensee did drop-off R1 at Kaiseer Richmond hospital and Licensee replied she called a transport for R1, The Administrator provided R1's cellular number for LPA to confirm or deny that R1 left willing. At 10:00 AM there was no answer when LPA called R1. LPA left a voicemail for R1. The complaint was received alleging illegal eviction. Based on record review, the eviction process does not meet the requirements of eviction notices under health and safety 1569.683. ...continued on LIC 9099C Substantiated ...continued from LIC 9099 Based on LPA's observations and interviews which were conducted and record reviews, 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), is being cited on the attached LIC 9099D. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 4, 2022 · control 15-AS-20220328152756

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.683(a) · Plan of correction due date: Apr 4, 2022

1569.683 Eviction Notices...(a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident...In addition, the notice to quit shall include all of the following: This requirement was not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. The notice did not follow appropriate steps established by which posed an immediate Health & Safety risk to resident in care.the state’s words, verbatim · CDSS document, Apr 4, 2022

Plan of correction: Administrator agrees to review regulation and submit a self-certification letter to CCL by POC date of 04/11/2022