Jefferson Care Home

Type of visit: Required - 1 Year

On 06/21/2023 at 11:14 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Administrator Dennis Ambat and explained the purpose of the visit. LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 04/2023. At 12:02 pm LPA reviewed 4 residents records. At 12:45 pm, LPA reviewed 3 staff records and 3 of 3 were fingerprint cleared and associated to the facility. The following deficiency was observed during the visit: There is no pre-appraisal for the residents in care There is expired non-perishables foods in pantry Cleaning supplies observed unlocked Continued on 809-C.... ...Continued from 809 The following TA observed: The facility has three storage rooms that are classified as other rooms (staff/office) that need to be cleared out The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 21, 2023

Allegation investigated: Administrator handled resident roughly Administrator yells at resident

On 05/19/23 at 3:50PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator. Allegation: Administrator handled resident roughly Investigation Finding: Unsubstantiated During investigation, LPA interviewed residents (R2, R3). Residents confirmed with LPA that staff (administrator, S1) never handled them roughly. R2 and R3 stated staff always treat them with respect and assist them with their activities of daily living (ADLs) feed them 3 meals a day plus snacks, assist them with their doctors' appointments, go on outings and shopping. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Administrator handled resident roughly Investigation Finding: Unsubstantiated Continuation: Witness (W1) confirmed with LPA that she never witnessed staff yell or hit any resident (R1, R2, R3) at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that the administrator handled resident roughly is unsubstantiated. Allegation: Administrator yells at resident Investigation Finding: Unsubstantiated During investigation, administrator (ADM) stated that resident (R1) has muscular dystrophy which affected her hearing muscles requiring him to get close to R1 and speak louder so she can hear him. R1 passed away under hospice care on 01/20/22. Staff (ADM, S1) denied yelling or hitting any resident at the facility. Residents (R2, R3) confirmed with LPA that staff do not yell or scream at them. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that administrator yells at resident is unsubstantiated. Exit interview conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, May 19, 2023 · control 15-AS-20220111112239

Allegation investigated: Staff are not being properly trained

On 3/29/23 at 10:40 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander arrived unannounced to conduct complaint investigation for the above allegations. LPAs met with Administrator, Stewart Morris and explained the purpose of the visit. During the course of the investigation, LPA L. Francisco obtained information, reviewed records, collected documents, interviewed staff and residents. It was alleged staff are not being properly trained. Based on record review on 3/29/23 at 11:20 AM, LPAs observed S2 did not receive the proper training requirements upon being hired in October of 2022. Based on LPAs 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. Appeal Rights and a copy of this report provided to Administrator. Substantiated This agency has investigated the complaint alleging uncleared adult providing care to residents and uncleared adult in home not wearing a mask. 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. Exit interview conducted and a copy of this report provided to Administrator.the state’s words, verbatim · CDSS document, Mar 29, 2023 · control 15-AS-20220106085047

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Apr 7, 2023

87411(c) PERSONNEL REQUIREMENTS - GENERAL (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Based on record review, LPAs observed S2 did not meet training requirements upon being hired in October of 2022 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: By POC date, Administrator agrees to submit a training schedule for S2 or a copy of completed training in accordance to the regulation Title 22 and Health and Safety to CCLD

Allegation investigated: Staff are not providing adequate food service to residents

On 3/29/2023 at 10:40 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander arrived unannounced to conduct complaint investigation for the above allegation. LPAs met with Administrator, Stewart Morris and explained the purpose of the visit. During the complaint investigation, LPAs inspected food supply and interviewed 3 clients. LPAs observed 2-day perishable and one week non-perishable food supply. LPAs interviewed 3 residents and 3 of 3 stated they are provided adequate food. 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. Exit interview conducted and a copy of this report provided to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 29, 2023 · control 15-AS-20230329120234

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 - Deficiencies

On 3/29/2023 at 11:45 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander arrived conducted Case Management visit while at the facility for complaint #15-AS-20220106085047 and #15-AS-20230329120234. LPAs met with Administrator, Stewart Morris. At 12:05 PM, LPA observed R2 buckled in the wheel chair. Administrator stated that resident was admitted to the facility on 3/1/2023 with the wheelchair. LPA did not observe a doctor's order on file. At 2:25 PM, Administrator had R2 demonstrate to LPAs if R2 is able to unbuckle independently. However, R2 was unable to unbuckle the wheelchair belt. The following deficiency observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency 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 29, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(1) · Plan of correction due date: Apr 14, 2023

87608(a)(1) POSTURAL SUPPORTS (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position.... This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the regulation cited above. LPA observed a belt on R2's wheel chair strapped around R2's waist. R2 was not able to remove buckle independently which poses a potential personal rights to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: By POC date, Administrator agrees to submit an exception request and include physician's report, Care Plan, and doctor's order to CCLD

Type of visit: Case Management - Other

On 3/29/2023 at 10:40 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander arrived unannounced for a Case Management to deliver amended report from visit on 10/15/2021. LPAs met with Administrator, Stewart Morris and explained the purpose of the visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 29, 2023

Type of visit: Required - 1 Year

On 06/30/2022 at 12:25 pm Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Licensee Stewart Morris and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 30, 2022

Type of visit: Case Management - Deficiencies

On 05/12/2022 at 08:45 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Caregiver Evan Park (S1). The staff called the Licensee Stewart Morris and informed him of the visit. Stewart notified the LPA and the staff that he would not be able to make it to the facility. The Licensee dedicated S1 to sign off on the report. LPA via phone explained the reason for the visit to Stewart. The LPA is following up about the claims that Stewart had made about having updated documentation regarding the control of property. As stated in the case management report dated 04/27/2022 “CCLD received a documentation that the facility was legally obligated to close and the property is to be sold. Stewart stated that the document that was being referred to was not the most up to date document and that there was no plan at this time the property was being sold.” The Licensee was given till 05/06/2022 to provide CCLD and RCEB with these documents. As of 5/12/2022 both RCEB and CCLD have not received any of the requested documentation. The Licensee made a false claim, that he had documentation that contradicted the document that was submitted to CCLD. The deficiency was observed (see LIC809-D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, May 12, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: May 26, 2022

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidence by: Based on observation, interview, and record review, the licensee did not comply with the section cited above: By claiming that they would submit documentation that proves they still have control of property.the state’s words, verbatim · CDSS document, May 12, 2022

Plan of correction: Administrator needs to submit clear documentation about status of property by POC date.

Type of visit: Case Management - Deficiencies

On 05/12/2022, during the course of another visit, Licensing Program Analyst (LPA) J. Clancy-Czuleger observed a pill bottle left out on the desk. LPA interviewed staff about the bottle and determined that it was empty. LPA then asked the staff to open any unlocked drawers in office/desk area. LPA then observed a bottle of pills left in an unlocked drawer. REPEATED VIOLATION CIVIL PENALTY ASSESSMENT: Medication bottle left accessible to residents 87465(h)(2) repeat violation from 10/15/2021 The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted With Caregiver Evan Park. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, May 12, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 13, 2022

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees.. This requirement is not met as evidenced by: Based on observation and interview, Licensee did not comply with the regulation cited above, LPAs observed unlocked medication inside office drawer, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2022

Plan of correction: DEFICIENCY CLEARED DURING VISIT. In addition, Administrator will review regulations and conduct an in-service training with staff and submit a copy of training agenda to CCL 5/26/2022. A $1000 Civil Penalty is being assessed for Repeat Violation

Type of visit: Case Management - Other

On 04/27/2022 at 2:30 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger and RCEB quality insurance specialist Synthia Hakola arrived unannounced to conduct a Case Management. LPA met with Stewart Morris, Licensee. CCLD received a documentation that the facility was legally obligated to close and the property is to be sold. Stewart stated that the document that was being referred to was not the most up to date document and that there was no plan at this time the property was being sold. Stewart said that he will get up dated documentation and send it to CCLD and to RECB by 5/6/2022 or additional information if that time line is not able to be metthe state’s words, verbatim · CDSS document, Apr 27, 2022

Allegation investigated: Staff hits resident Staff yells at residents Staff is incompetent with providing proper care for residents Facility failed to arrange a follow-up appointment for residen

On 10/29/21 at 2:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint investigation and delivered the findings with administrator (ADM). LPA explained the purpose of the visit with ADM. Allegation: Staff hits resident Investigation Finding: Unsubstantiated LPA interviewed residents (R1, R2 & R3) during visit. They confirmed with LPA that staff never hit them. LPA observed R1, R2 and R3 to be well groomed, clean and relaxed in their environment. Witness (W1) also confirmed with LPA that staff never hit any resident at the facility. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff yells at resident Investigation Finding: Unsubstantiated LPA interviewed residents (R1, R2 & R3) during visit. They confirmed with LPA that staff never yells at them. Witness (W1) also confirmed with LPA that staff never yells at residents. Allegation: Staff is incompetent with providing proper care for residents Investigation Finding: Unsubstantiated LPA interviewed residents (R1, R2 & R3) during visit. They confirmed with LPA that staff take good care of them such as assist them with activities of daily living (ADLs), feed them 3 meals a day plus snacks, assist them with their doctors' appointments, go on outings and shopping. R1, R2 and R3 told LPA that they feel safe living at the facility and treat staff as family since they have lived at the facility for more than 8 years. Allegation: Facility failed to arrange a follow-up appointment for resident Investigation Finding: Unsubstantiated ADM told LPA that R1 broke her right thumb on 09/26/21 when she had an unwitnessed fall in her bedroom around 7PM. ADM called 911 but R1 refused to go with the paramedics. The next morning (09/27/21) ADM took R1 to the hospital to get her right thumb evaluated and treated. R1 was treated with a cast on her thumb and released back to the facility the same day. LPA observed R1 able to move her right elbow and thumb without any noticeable signs of pain or discomfort during visit. ADM told LPA he has been trying to get R1's follow-up doctor's appointment to no avail. ADM stated the county told him that R1's follow up appointment is not available for another 7 weeks. He also never got any response from R1's Medi-Cal agency. He told LPA he will take R1 to the hospital ER on 10/30/21 to get R1's cast removed. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 29, 2021 · control 15-AS-20211022145432

Allegation investigated: Different adults are staying at the facility without clearance.

On 10/15/2021 starting at 2:15pm, Licensing Program Analysts (LPAs) L. Francisco and J. Clancy-Czuleger arrived unannounced to conduct a complaint investigation for the above allegation. LPAs met with Administrator, Steward Morris and explained the purpose of the visit. Regional Center of East Bay (RCEB), Synthia Hakola later arrived at 2:48pm to join LPAs. Durring the complaint investigation, LPAs obtained information, collected documents, interviewed staff and witness. On 10/11/2021 W1 conducted a visit and met with S2 who is not finger print cleared. Interview with S1 on 10/15/2021 revealed S2 was left with a resident on 10/11/2021. REPORT CONTINUES ON 9099C Substantiated Based on LPAs 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), are being cited on the attached LIC 9099D. A repeat $250 and immediate $500 civil penalties are being assessed. Exit interview conducted. Appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 15, 2021 · control 15-AS-20211011163104

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 16, 2021

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review.....1) Obtain a California clearance or a criminal record exemption as required by the Department… This requirement was not met as evidence by: Based on interview and record review, the licensee did not comply with regulation above. S1 confirmed S2 was left alone with a resident on 10/11/2021 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2021

Plan of correction: By POC date administrator will review regulation and submit self certification letter that S2 is not to return to facility untill finger print cleared.

Allegation investigated: Medications were left accessible to clients in care. Staff does not meet training requirements Building alteration

On 10/15/2021 starting at 2:15pm, Licensing Program Analysts (LPAs) L. Francisco and J. Clancy-Czuleger arrived unannounced to conduct a complaint investigation for the above allegations. LPAs met with Administrator, Stewart Morris and explained the purpose of the visit. Regional Center of East Bay (RCEB), Synthia Hakola later arrived at 2:48pm to join LPAs. Durring the complaint investigation, LPAs obtained information, collected documents, interviewed staff and witness. Allegation: Medications were left accessible to clients in care. During LPAs tour of facility, LPAs observed unlocked medication in staff's room. On 10/11/2021, W1 observed unlocked medication inside office drawer. REPORT CONTINUES ON 9099C Substantiated Allegation: Staff does not meet training requirements Based on interview with W1, S2 is administering medications to residents and attaching a post it note on Medication Administration Record (MAR) for S1 to initial. Facility was unable to provide proof of training for S2. Allegation: Building alteration On 10/15/2021 during LPAs tour of facility, LPAs observed a room was added in the living room. LPAs observed 1 of 3 residents is occupying the added bedroom. However, there is no building permit or approved fire inspection on file. 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. An immediate $500 Civil Penalty is being assessed. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 15, 2021 · control 15-AS-20211012134600

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Oct 16, 2021

87202 FIRE CLEARANCE (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services.... This requirement is not met as evidenced by: Based on observation and record review, Licensee did not comply with the regulations cited above. LPAs observed additional bedroom is not cleared by Fire Department which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2021

Plan of correction: By POC date, Administrator agrees to transfer resident from unapproved fire clearance room into the vacant room that is indicated on the floor plan approved by the Fire Department. Administrator will submit a photo and self-certification to CCL by 10/16/2021.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 16, 2021

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees.. This requirement is not met as evidenced by: Based on observation and interview, Licensee did not comply with the regulation cited above. On 10/11/21, W1 observed unlocked medication inside office drawer. LPAs observed unlocked medication in staff's room which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2021

Plan of correction: DEFICIENCY CLEARED DURING VISIT. In addition, Administrator will review regulations and conduct an in-service training with staff and submit a copy of training agenda to CCL 10/28/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Oct 29, 2021

***This is an amended report from visit on 10/15/2021*** 87305 ALTERATIONS TO EXISTING BUILDING... (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Based on observation and record review, Licensee did not comply with the regulation above. LPA observed walls were added to the living room to be converted into a bedroom which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2021

Plan of correction: ***This is an amended report from visit on 10/15/2021*** By POC date, Administrator agrees to obtain a permit, complete LIC 200 and floor plan, and submit a copy to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Dec 30, 2022

***This is an amended report from visit on 10/15/2021*** 87411(c) Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above not meeting the training requirements for S2 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 15, 2021

Plan of correction: ***This is an amended report from visit on 10/15/2021*** By POC date, Administrator agrees to review regulation and submit self-certification letter of understanding to CCLD.

Type of visit: Case Management - Other

On 10/5/2021 at 11:00AM Licensing Program Analyst ( LPA ) L. Ibo conducted an unannounced follow up case management visit , LPA met with Administrator Stewart Morris. There were 2 residents at the facility during the visit, there are at least 7 days non-perishable and 2 days perishable food supplies. Per Administrator he will keep calling staffing agency for additional staffing this week. Per Administrator additional staffing will be at the facility starting 10/9/2021. LPA requested for an updated LIC500 to reflect staffing schedule. No citation noted during the visit, copy of this reported provided to Administrator.the state’s words, verbatim · CDSS document, Oct 5, 2021

Allegation investigated: Illegal eviction

On 10/1/2021 at around 11:35 AM, Licensing Program Analyst (LPA) L. Ibo and RCEB Quality Assurance ( Q.A) Synthia Hakola conducted a joint visit at the facility to conduct investigation for the above allegation. LPA & QA met with Administrator Stewart Morris. LPA informed Administrator the purpose of the visit. During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. According to Administrator the facility is not closing, based on LPA interview with a resident, R2 is moving out voluntarily. Two other residents moved out 10/1/2021 per Administrator. LPA observed during the visit that family of R5 & R6 moved out residents’ belongings. 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. Exit interview conducted, copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 1, 2021 · control 15-AS-20210929100712

Type of visit: Case Management - Other

On 10/1/2021, during the course of another visit, Licensing Program Analyst ( LPA ) L. Ibo and Regional Center of East Bay QA Synthia Hakola conducted a joint case management visit, LPA observed that R1 has bruises on her left side of her face and wearing a cast and arm sling. LPA conducted interview with staff and resident, and requested for the following documents; LIC602a , special incident report (SIR) , and LIC500. LPA interviewed resident (see lic812 fore detailed information) Exit interview conducted, copy of this report provided.the state’s words, verbatim · CDSS document, Oct 1, 2021

Type of visit: Case Management - Other

On 10/1/2021, during the course of another visit, Licensing Program Analyst ( LPA ) L. Ibo and Regional Center of East Bay QA Synthia Hakola conducted a joint case management visit . LPA interviewed resident and staff. Based on the interview, one staff (S2) was present at the facility on 10/1/2021 and worked early morning shift (breakfast) . Based on the interview with residents S2 has been working at the facility for about a month now. LPA conducted records review using guardian system and S2 is not finger print cleared from DOJ & FBI. $500.00 Civil penalty was assessed. Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 1, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 1, 2021

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review.....1) Obtain a California clearance or a criminal record exemption as required by the Department… This requirement was not met as evidence by: Based on observation, interview, and record review, the licensee did not comply with the section cited above S2 started working at the facility for about a month , LPA conducted records review using guardian system and S2 is not finger print cleared which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2021

Plan of correction: Administrator needs to inform S2 not to come back at the facility until S2 is finger print cleared from DOJ and FBI. Administrator needs to submit staff roster once S2 is fingerprint cleared and part of LIC500. $500.00 Civil penalty was assessed.