Belrose Care Home III

Allegation investigated: Resident's bed is blocked by another piece of furniture preventing passage around the room.

On 04/12/2023 at 8:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a complaint inspection. LPA explained purpose of the visit to Caregiver Evangeline Polito, who toured facility with LPA. Licensee Rosa Junsay arrived at 10:50 AM. At 8:15 AM, LPA observed furniture matching that sent by Complainant in resident R1's room. When asked, Caregiver Polito confirmed that it was used to block R1's exit from the bed at night. Based on the data collected by observation and interview, the preponderance of evidence standard has been met; therefore, the above allegation has been found to be SUBSTANTIATED. Deficiency cited per Title 22 California Code of Regulations is listed on the LIC9099-D. Failure to submit proof of correction (POC) 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 via email. Substantiatedthe state’s words, verbatim · CDSS document, Apr 12, 2023 · control 15-AS-20230411154803

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 19, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents ... shall have all of the following personal rights: (3) To be free from ... interfering with daily living functions such as ... elimination. This requirement was not met as evidenced by: Based on observation and interview, the licensee blocked resident R1's ability to leave her bed to use the bathroom, which did not comply with the section cited above, which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 12, 2023

Plan of correction: On or before due date, Licensee shall get an updated Care Plan from R1's physician addressing her night wandering behavior.

Type of visit: Case Management - Deficiencies

On 04/12/2023, during an unannounced complaint inspection, Licensing Program Analyst (LPA) J. Sampair observed a bed railing on resident R1's bed without a physician's order and Caregiver Evangeline Polito who was not associated with the facility for which a civil penalty was issued. Deficiencies cited per Title 22 California Code of Regulations is listed on the LIC9099-D. Failure to submit proof of correction (POC) 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 via email.the state’s words, verbatim · CDSS document, Apr 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Apr 13, 2023

87608 POSTURAL SUPPORTS (a) ... Postural supports may be used under the following conditions ... (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. This requirement was not met as evidenced by: Based on observation and record review, the licensee did not have a physician's order for a bed railing for R1, which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 12, 2023

Plan of correction: Bed raining was removed from resident R1's bed during the visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(g)(1) · Plan of correction due date: Apr 13, 2023

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance This requirement was not met as evidenced by: Based on observation and record review, the licensee did not have a physician's order for a bed railing for R1, which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 12, 2023

Plan of correction: Transfer association to facility on or before due date.

Type of visit: Required - 1 Year

On 1/30/2023 at 2:45 PM, Licensing Program Analyst (LPA) James Sampair arrived to conduct an unannounced required annual inspection. LPA explained the purpose of the visit to Administrator (ADM) Rosa Junsay. LPA and ADM inspected facility inside and out. The facility has an infection mitigation plan in place, and the Infection Preventionist is the ADM. Staff were following the latest COVID-19 infection control guidance. They have one central entry point at the front entrance and they were logging visitor information including temperature. There was at least 7 days of nonperishable and 2 days of perishable foods. Hot water and facility room temperatures maintained at comfortable temperatures. Fire extinguisher was fully charged and serviced within the past year. Carbon monoxide and smoke detectors operational. Administrator is on site a minimum of 20 hours a week to oversee proper business operation. No citations issued during inspection. Administrator to send updated copies of these documents to CCL on or before 02/06/2023: LIC500 - Personnel Report LIC610D - Emergency/Disaster Plan Evidence of sufficient Liability Insurance Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Jan 30, 2023

Allegation investigated: Facility staff mismanaged resident's medication.

On 8/22/2022 at 12:45PM, Licensing Program Analysts (LPAs) G. Luk and J. Sampair arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPAs met with Administrator, Rosa Junsay. During the course of investigation, LPA G. Luk interviewed 3 staff and complainant. LPAs obtained and reviewed documents including physician's report, medication administration records, centrally stored medication list, hospice nurse contact information, and list of medications from the doctor. Record review indicated that R1's current medication list for Metoprolol was prescribed to take 1 tablet once daily. However, MAR (Medication Administration Record) dated February 2022 states that Metoprolol was given twice a day. Based on LPA's 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, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 22, 2022 · control 15-AS-20210803160230

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 2, 2022

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not administering medication according to doctor's orders which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2022

Plan of correction: Administrator has agreed to retrain all staff on medication administration and medication documentation. Administrator will submit staff sign-in sheet and training materials to CCLD by POC date.

Type of visit: Case Management - Other

On 8/22/2022 at 2:30PM, Licensing Program Analysts (LPAs) G. Luk and J. Sampair arrived unannounced to conduct a case management visit. LPAs met with Administrator, Rosa Junsay. While LPAs was conducting a complaint investigation to deliver findings, the following deficiency was observed. During complaint investigation, it was observed that facility did not have pre-placement appraisal or care plan for R1. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 22, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Sep 2, 2022

Pre-Admission Appraisal - General. Prior to admission...an appraisal of his/her individual service needs in comparison with the admission criteria... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not obtaining pre-placement appraisal which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2022

Plan of correction: Administrator has agreed to review regulations regarding to admission of a new resident. Administrator will submit a written statement acknowledging that all current and future residents will have a pre-placement appraisal to CCLD by POC date.

Type of visit: Required - 1 Year

On 04/18/2022 at 10:00 AM, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced infection control and required one year inspection. Upon arrival, LPA was greeted by staff S1. LPA explained the purpose of the visit to S1 and toured the facility inside and outside. Director Rosa Junsay arrived at 10:45 AM and toured the facility with the LPA. LPA observed staff wearing face masks during visit and their use of a visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe for screening. LPA observed COVID-19 signs posted in common areas to promote hand washing, cough/sneeze etiquette, and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks. During the visit, pathways were observed to be free of obstruction and fire hazards. Last Fire drill was conducted in February 2022 for which Ms. Junsay will send electronic proof to LPA by 04/19/2022.. Facility room temperature was maintained at a comfortable 68.7 degrees Fahrenheit and the hot water temperature was 111 degrees Fahrenheit. The facility was cited for the numerous physical plant updates and repairs needed. Additionally, Licensee will send the following by 04/19/2022 to LPA: Copy of Quarterly Emergency Disaster Drill log Personnel Report (LIC500) Exit interview conducted and a copy of this report was providedthe state’s words, verbatim · CDSS document, Apr 18, 2022