The Stuart House

Type of visit: Required - 1 Year

On 9/23/2023 at 12:45PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Pamela Green, Administrator and explained the purpose of the visit. The Administrator currently holds a certificate (#6024026740) that expires on 02/10/2025. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 114.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/18/2023. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809. LPA reviewed three (3) staff files all are incomplete. All four (4) residents' file were reviewed and all were incomplete. LPA observed the following deficiencies: At 1:00pm, LPA observed during record review all of the resident files are incomplete. At 1:30pm, LPA observed during record review all three (3) staff files are incomplete. At 1:35pm, LPA observed during record review two (2) of three (3) staff do not have first aid certification. LPA requested the following documents to be submitted to CCLD by 10/2/2023. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (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. A copy of appeal rights and this report provided.the state’s words, verbatim · CDSS document, Sep 23, 2023

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff denied resident visitors

On 5/12/2023 at 12:05 PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with by Administrator, Pamela Green and explained the reason for the visit. During the complaint investigation, LPA interviewed RP and 1 staff. LPA reviewed and obtained the following documents for R1: (physician reports, admission agreement, identification and emergency information, and Power of Attorney (POA), hospice care plan, after visit summary, hospice plan of care order, conservatorship court document, letter from Sutter Health and progress notes. Unsubstantiated Continue from LIC9099 ALLEGATION: Staff denied resident visitors Investigation finding: UNSUBSTANTIATED Interview with RP revealed S1 denied a visit with R1. When RP arrived at the facility RP was informed by S1 that R1 had a visit for the day and would not be able to have another visitor for the day. Interview with S1 revealed that R1 has a note from R1’s doctor stating it is recommended that R1 visits are limited to one person per day for no more than 30 minutes Interview with W1 revealed that W1 agrees with the recommendations of the doctor and wishes to limit visitation one person per day no longer than 30 minutes. 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 and copy of report provided.the state’s words, verbatim · CDSS document, May 12, 2023 · control 15-AS-20230419164121

Type of visit: Case Management - Other

On 4/26/2023 at 9:28AM, Licensing Program Analyst (LPA) C. Fowler conducted an unannounced Case Management visit to deliver an amended complaint #15-AS-20220926082823. LPA met with administrator Pamela Green and explained the purpose of the visit. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 26, 2023

Type of visit: Case Management - Other

On 4/26/2023 at 9:28AM, Licensing Program Analyst (LPA) C. Fowler conducted an unannounced Case Management visit to retrieve documents dated 4/4/2023 that was generated in error. LPA met with administrator Pamela Green and explained the purpose of the visit. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 26, 2023

Allegation investigated: Staff fail to ensure footrests were on the wheelchair Staff did not providing proper care

On 4/04/2023 at 3:05 PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct a complaint investigation for the above allegations. Upon arrival, LPA met with by Administrator, Pamela Green and explained the reason for the visit. During the complaint investigation, LPA interviewed RP and 2 staff. LPA collected the following documents: reviewed and obtained the following documents for R1: (physician reports, admission agreement, identification and emergency information, and Power of Attorney (POA), hospice care plan, after visit summary, hospice plan of care order and progress notes. CONTINUE ON LIC9099C Unsubstantiated CONTINUE FROM LIC9099 ALLEGATION: Staff fail to ensure footrests were on the wheelchair Investigation finding: UNSUBSTANTIATED During the course of the investigation the Department interviewed 2 staff, and reporting party (RP) LPA obtained & reviewed the following documents: Facility & staff roster, physician reports, admission agreement, identification and emergency information, and Power of Attorney (POA), hospice care plan, after visit summary, hospice plan of care order and progress notes. Interview wit's been requested and order. S1 stated that S1 uses a wheelchair that belonged to R2 to bring R1 to the visiting area and is then put into a recliner with pillows and warming blankets for visits. ALLEGATION: Staff did not providing proper care Investigation finding: UNSUBSTANTIATED During the course of the investigation the Department interviewed 2 staff and reporting party (RP). Interview with staff and record review revealed hospice nurse and in home care aid is visiting the facility 3 times a week and is taking care of R1. Hospice nurse is caring for R1's diagnoses, the in-home care aid is taking care of R1 hygiene. 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 and copy of report provided.the state’s words, verbatim · CDSS document, Apr 4, 2023 · control 15-AS-20230310090505

Allegation investigated: Staff denied resident phone calls Staff denied resident visitors

This is an amendment to the original 9099 dated 03/16/2023 On March 16, 2023, at 3::05PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced visit to deliver the findings on the above allegations and met with Co-Owner Jimmy Stuart and disclosed the purpose of the visit and was granted entry into the facility by Jimmy Stuart Co-Owner. 4 residents and 2 staff were present in the facility during this visit. The facility is a 4-bedroom 2-bath house. During the course of the investigation the Department interviewed 1 staff, and Reporting Party (RP); obtained & reviewed the following documents for R1: physician reports, admission agreement, identification and emergency information, and Power of Attorney (POA). facility and staff roster were requested and received by CCLD via email on 10/03/2022. Continue on LIC9099C Substantiated Continue from LIC 9099 Staff denied resident phone calls: SUBSTANTIATED RP stated that R1 moved into the facility on August 20, 2022, RP called the facility to speak with R1 and first spoke with S1, RP stated that S1 wanted to know who she was because R1 kept asking for her. RP stated that she spoke with R1 and R1 sounded drugged. RP stated that S1 informed her that R1 could not have any visitors, calls or facetime for 30 days per her house rules during transition period. RP stated that she informed S1 that RP birthday is coming up within a few days and RP would like to see R1. RP stated that when RP called the facility on 9/27/2022 S1 would not put R1 on the phone until W2 was connected to the call. RP stated that RP called the facility on 9/30/2022 at 3:00pm and 4:19pm there was no answer RP left a message and received a call back from S1 that informed her she needs to call between the hours of 10:00am and 4:00pm and R1 was not at the facility she was at a doctor appointment. RP stated that she made an appointment to visit R1 on 10/01/2022. RP stated that RP called on scheduled day to make an appointment to visit, RP called at 12:00pm, 1:00pm and 3:48pm and left a message each time and there was no call back. RP stated that on 12/16/2022 RP called to schedule an appointment to visit and left a message with no call back. RP stated that on March 10, 2023 RP call local law enforcement (Richmond Police Department) to conduct a welfare check because RP has not been able to reach R1 by phone since March 3, 2023. Staff denied resident visitors: SUBSTANTIATED RP stated that RP and W1 was parking outside of the facility and S1 came outside and informed them that they could not see R1 and R1 is in the facility eating cake. RP stated that they left flowers, a card and balloons for R1. RP stated on 10/07/2022 RP was speaking with R1 and the phone got disconnected, RP stated she called back and the phone went to voicemail RP left a message stating that RP would call back after 1:00pm. RP stated that she called back at 2:57pm and reminded S1 that she has a scheduled visit and S1 stated she did not remember RP booking anything and the facility is booked, and she could come on Tuesday 10/10/2022. RP stated she could take R1 out so that RP would not interrupt the other visitors. Continue on LIC9099 Continue on LIC9099 Staff denied resident phone calls: SUBSTANTIATED RP stated that R1 moved into the facility on August 20, 2022, RP called the facility to speak with R1 and first spoke with S1, RP stated that S1 wanted to know who she was because R1 kept asking for her. RP stated that she spoke with R1 and R1 sounded drugged. RP stated that S1 informed her that R1 could not have any visitors, calls or facetime for 30 days per her house rules during transition period. RP stated that she informed S1 that RP birthday is coming up within a few days and RP would like to see R1. RP stated that when RP called the facility on 9/27/2022 S1 would not put R1 on the phone until W2 was connected to the call. RP stated that RP called the facility on 9/30/2022 at 3:00pm and 4:19pm there was no answer RP left a message and received a call back from S1 that informed her she needs to call between the hours of 10:00am and 4:00pm and R1 was not at the facility she was at a doctor appointment. RP stated that she made an appointment to visit R1 on 10/01/2022. RP stated that RP called on scheduled day to make an appointment to visit, RP called at 12:00pm, 1:00pm and 3:48pm and left a message each time and there was no call back. RP stated that on 12/16/2022 RP called to schedule an appointment to visit and left a message with no call back. RP stated that on March 10, 2023 RP call local law enforcement (Richmond Police Department) to conduct a welfare check because RP has not been able to reach R1 by phone since March 3, 2023. Staff denied resident visitors: SUBSTANTIATED RP stated that RP and W1 was parking outside of the facility and S1 came outside and informed them that they could not see R1 and R1 is in the facility eating cake. RP stated that they left flowers, a card and balloons for R1. RP stated on 10/07/2022 RP was speaking with R1 and the phone got disconnected, RP stated she called back and the phone went to voicemail RP left a message stating that RP would call back after 1:00pm. RP stated that she called back at 2:57pm and reminded S1 that she has a scheduled visit and S1 stated she did not remember RP booking anything and the facility is booked, and she could come on Tuesday 10/10/2022. RP stated she could take R1 out so that RP would not interrupt the other visitors. S1 stated that she must speak with W3. RP stated that S1 stated that I do not have a court order. RP stated that she then told S1 that RP doesn’t need a order and the only time there is an order is when the court doesn’t want someone to take R1 out. RP asked S1 if she has an order. S1 refused to let RP take her out for a visit. Continue from LIC9099C RP stated that RP made an appointment to visit with R1 on 12/7/2022 with S1. On 12/6/2022 RP stated that she called the facility to inform S1 that she will be bringing someone with RP to visit. RP stated that she spoke with S2 and informed S2 that RP would be bringing someone with RP, RP stated that S2 stated S2 would inform S1. RP stated that RP received a phone call from S1 stating S2 didn’t inform S1 until the morning of 12/7/2022. RP stated that RP informed S1 that it’s not her fault S2 didn’t inform S1 RP was bringing someone to visit. LPA interviewed S1, S1 stated W3 has power of attorney over medical and finances. S1 stated that she would like to speak to one of the siblings about R1’s health care and that person to inform the other siblings. S1 stated that R1 was not allowed to have any phone calls or visits with anyone for the first 30 days of moving into the facility, S1 stated this is so R1 could get acclimated to the facility and staff, S1 stated this is the facilities house rule, (which is not in writing or a part of the admissions agreement. Facility admission agreement visiting policy states family and friends are encouraged to visit anytime from 10:00am to 5:00pm). S1 made a schedule for R1’s children to call the facility and to also schedule appointments to visit R1 at the facility. 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 exit interview was conducted and Plans of Correction were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 15-AS-20220926082823

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Mar 24, 2023

(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during... hours and without prior notice, provided that the rights of other residents are not infringed upon. Based on LPA's observation licensee did not comply with the section cited above which poses a potential health and safety risk to clients.the state’s words, verbatim · CDSS document, Mar 16, 2023

Plan of correction: Administrator will read and understand regulation. Submit self certification to CCLD no later then the POC date. Administrator will also add an addendum to the facilities Plan of Operation about residents visitors rights, to be submitted to CCLD no later then POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Apr 24, 2023

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. Based on LPA's observation licensee did not comply with the section cited above by restricting R1 phone calls with family which poses a potential health and safety risk to clients.the state’s words, verbatim · CDSS document, Mar 16, 2023

Plan of correction: Administrator will read and understand regulation. Submit self-certification to CCLD no later than the POC date.

Type of visit: Required - 1 Year

On 5/23/2022 at 9:30 am, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Pamela Green and explained the purpose of the visit. Upon entry, LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathroom, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters. During record review, LPA observed visitors log and temperature logs for residents or staff. LPA observed facility has a copy of Mitigation Plan on file. The following deficiencies were observed during the visit: -At 9:54am, LPA observed unlocked knives in cabinet under the sink. -At 10:01am, LPA observed gardening tools shovels, rake, ladders outside of the locked shed. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, May 23, 2022

Type of visit: Required - 1 Year

On 7/14//2021 at 9:45AM, Licensing Program Analysts (LPAs) L. Hall and C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPAs met with Administrator, Pamela Green and explained the purpose of the visit. Upon entry, LPAs temperatures were not checked, LPAs observed hand sanitizer, and COVID-19 signage at screening station. LPAs toured facility including but not limited to common areas, bathroom, kitchen, garage, and backyard. All sinks were equipped with soap, paper towel, and hand washing signs. During record review, LPAs observed visitors log and temperature log for both residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPE, food and paper supplies are sufficient. No deficiencies were cited during this inspection. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jul 14, 2021