Brookdale Diablo Lodge

Allegation investigated: Personal Rights - Facility has inadequate record keeping of a resident while in care Personal Rights - Staff did not address a resident change in medical condition Personal Rights - Resident sustained injuries from multiple falls while in care Personal Rights - Staff did not follow a resident's care plan while in care Personal Rights - Staff did not properly report incidents involving a resident Personal Rights - Staff did not provide adequate care and supervision to a resident

On 11/1/2023 starting at 12:45 PM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to deliver findings for the above allegations. AGPA met with Life Enrichment Manager, Paula Arce and explained the purpose of the visit. During course of the investigation, the Department conducted interviews with facility staff, witness and complainant. Documents including but not limited to: R1’s physician’s report, care plan, medication log, incident reports, hospice care notes, progress notes, and death certificate were obtained. Allegation: Personal Rights - Facility has inadequate record keeping of a resident while in care However, based on record review of R1’s progress notes and incident report, AGPA observed a history of notes by staff regarding R1’s fall and any changes in condition observed from March of 2022 to August of 2022. REPORT CONTINUES ON 9099C Unsubstantiated Allegation: Personal Rights - Staff did not address a resident change in medical condition However, based on interview with staff and W1, hospice was notified whenever staff observed a change in condition and nurse from hospice was requested by facility to assess resident. R1 was admitted to facility on January of 2022 and AGPA observed Personal Service Plan was updated, 3/4/22, and 8/22/2022 to address R1’s change in condition. Allegation: Personal Rights - Resident sustained injuries from multiple falls while in care Based on record review of incident report and progress notes, R1 had multiple unwitnessed falls on 1/28/22, 3/17/22, 8/12/22, and 8/14/22. However, no injuries were noted. R1 was admitted to ER on 3/17/22 and xray was completed, but no fractures were sustained from the fall. Allegation: Personal Rights - Staff did not follow a resident's care plan while in care Based on interview with W1, facility was following resident’s care plan and was in communication with hospice. W1 did not feel that there was any neglect by the facility according to the records from the nurses in charge during the time R1 was under hospice care. Allegation: Personal Rights - Staff did not properly report incidents involving a resident Based on record review, responsible party was notified of R1’s multiple falls that occurred on 1/28/22, 3/17/22, 8/12/22, and 8/14/22. Allegation: Personal Rights - Staff did not provide adequate care and supervision to a resident Based on record review, facility addressed the concern with R1’s responsible party regarding R1’s multiple falls. A care conference was held on 8/15/2022 where facility recommended a 1:1 companion for R1 due to increased agitation. However, R1’s responsible party refused. R1 was being checked by staff every 2 hours. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of report provided to Life Enrichment Manager. Allegation: Personal Rights - Questionable Death The Department obtained a copy of R1’s death certificate where it indicates that the cause of death was due to chronic congestive heart failure and coronary artery disease. R1 was admitted to hospice on July 25, 2022 and was diagnosed with heart failure and not related due to neglect of the facility. This agency has investigated the complaint alleging questionable death. 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 Life Enrichment Manager.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 15-AS-20230118130142

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) A. Gomez and Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to conduct a 1-Year Annual Required visit on this date starting at 10:40AM. Upon arrival, LPA and AGPA met with Executive Director, Rachael Davis. The facility's fire clearance was approved for all may be non-ambulatory of which 8 may be bedridden. LPA and AGPA toured the facility inside and out with Executive Director including but not limited to facility hallways, activity room, dining room, kitchen, resident rooms and medicine room. Indoor and outdoor passageways were kept free of obstruction. There are no bodies of water observed. Hot water temperature in random resident's bedroom was maintained at 113.6 degrees F. In another Residents room, hot water temperature was maintained at 114.1 degrees F. A comfortable room temperature was maintained at 73 degrees F in the hallway. Facility was equipped with a minimum of one week supply of non-perishable and 2-day supply of perishable food. Medication carts were observed locked. LPA's reviewed a sample of medication. Fire extinguisher was last serviced on 09/12/2023. Smoke detectors and sprinklers are interconnected and observed throughout facility. LPA and AGPA reviewed 5 staff records and 5 of 5 are associated and have current first-aid training. LPA reviewed 5 residents records. The following deficiencies were observed At 12:17PM LPA's observed Miralax in R4's apartment. At 12:35PM LPA's observed TUMS in R5's apartment. REPORT CONTINUES ON 809C Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 11/02/2023: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate 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 with Executive Director. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 19, 2023

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility elevator does not meet backup power requirements. Staff did not follow emergency procedures during a power outage. Staff not trained on emergency procedures during a power outage.

On 07/10/2023 at 9:35 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to investigate the allegations above. Upon arrival, LPA stated purpose of the visit to Executive Director (ED) Rachel Davis and Health & Wellness Director (HWD) Jinder Kaur. During the LPA's investigation, the ED and HWD provided the requested records and spoke in detail with LPA about the backup requirements for their facility's elevators, the facility's emergency procedures, and the staff training on those procedures during a power outage. The LPA reviewed facility records that included the Emergency Manual, monthly safety drill records, and Unusual incident reports, and interviewed 1 resident and 2 staff members about R1 being trapped in an elevator during a power outage on 07/01/2023. (Continued on LIC9099-C...) Unsubstantiated (...Continued from LIC9099) Facility elevator does not meet backup power requirements. Based on a review of regulations, facility records, and interview of ED the facility elevator does meet the existing backup power requirements. Staff did not follow emergency procedures during a power outage. Based on interviews of R1, ED, HWD, S1, S3, and facility records, staff did follow emergency procedures during the power outage of 07/01/2023. Staff not trained on emergency procedures during a power outage. Based on interviews of ED, HWD, S1, S3, and facility records, staff was trained extensively on emergency procedures. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report emailed to ED.the state’s words, verbatim · CDSS document, Jul 10, 2023 · control 15-AS-20230703130036

Allegation investigated: Staff did not assist resident with her incontinence. The temperature was below the regulated limit.

On 3/30/23 at 2:15 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegations. LPA met with Executive Director, Rachael Davis and explained the purpose of the visit. During the course of the investigation, LPA obtained information, collected documents and interviewed staff and residents. It was alleged staff did not assist resident with her incontinence. However, interview with 4 staff revealed residents are checked every two hours and if the call button has been pressed. 6 of 6 stated that staff check on them and staff responds to the call button. No forthcoming information was obtained from reporting party. REPORT CONTINUES ON 9099C Unsubstantiated It was alleged the temperature was below the regulated limit. Based on observation, each apartments have its own air conditioner and heating. On 12/6/2021, S1 stated resident's apartments are equipped with smart thermostat where the temperature is set between 65 degrees F and 81 degrees F, but most rooms are set at 72 degrees F. S1 stated if residents are not able to set their own thermostat, residents will call concierge to have staff set temperature for residents. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided to Executive Director.the state’s words, verbatim · CDSS document, Mar 30, 2023 · control 15-AS-20211129095653

Allegation investigated: Facility does not have proper provisions for residents in the event of a power outage

On 3/30/2023 starting at 2:15 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. LPA met with Executive Director, Rachael Davis and explained the purpose of the visit. During the course of the investigation, LPA obtained information, collected documents, interviewed staff and residents. It was alleged facility does not have proper provisions for residents in the event of a power outage. However, based on record review and interview, Emergency Disaster Plan was implemented during the power outtage. LPA discovered during an interview with 2 residents that the power outtage occured late at night and residents were provided back-up oxygen tanks. 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 30, 2023 · control 15-AS-20220906133730

Type of visit: Case Management - Health Checks

On 1/19/2023 starting at 3:30 PM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson conducted a Health & Safety inspection as a result of a Priority 1 complaint. LPAs met with Executive Director, Rachael Davis and explained the purpose of the visit. LPAs toured facility including but not limited to the random apartments, bathrooms, common areas, and kitchen. A sample of hot water temperature were maintained at 114, 115.1, and 113.8 degrees F in random residents apartments. LPAs observed an adequate one week of non-perishable and 2-day of perishable food supply. Resident's medications were kept locked in the medication cart. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be fullt charged and last serviced on 8/10/2022. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING HEALTH & SAFETY INSPECTION At 3:30 PM, LPAs observed unlocked cleaning supplies, bug spray, and bleach inside kitchen cabinet and bathroom cabinets in R1's apartment At 3:36 PM, LPAs observed unlocked gardening tools, oxyclean, and comet. The following deficiency was observed (see LICd 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 to Executive Director.the state’s words, verbatim · CDSS document, Jan 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jan 20, 2023

87309(a) STORAGE SPACE Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the regulations cited above. LPAs observed unlocked cleaning supplies and gardening tools in R2's apartment; and cleaning supplies in R1's apartment which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 19, 2023

Plan of correction: By POC date, Administrator agrees to conduct room checks and submit a self-certification letter that cleaning supplies have been removed and locked away to CCLD

Type of visit: Required - 1 Year

On 09/15/2022 at 9:45 AM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson arrived unannounced to conduct Infection Control Inspection. LPAs met with Executive Director, Rachael Davis and Health and Wellness Director, Najinder Kaur, and explained the purpose of the visit. During the Infection Control Inspection, LPAs toured facility with Excutive DIrector and Health & Wellness Director including but not limited to front entrance, screening station, hand washing stations, apartments, common areas, dining room, multiple activity rooms, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. 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. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. At approximately 12:05 PM, LPAs reviewed 5 staff records and 5 of 5 have health screening and TB test results on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff. THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT: At 11:25 AM, LPAs observed two portable oxygen tanks in R1's apartment are without a stand. REPORT CONTINUES ON 809C Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/22/2022: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate 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, Sep 15, 2022

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility is not kept clean

On 11/18/2021 at 8:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegation above. LPA met with Executive Director, Bill Grady. During the investigation, LPA interviewed staff and complainant. LPA obtained and reviewed R1's file including physician's report, care plan, and care notes. LPA conducted a virtual tour of the facility and R1's room on 10/30/2020. LPA observed R1's room had stains on the carpet and bathroom had spots of brown/yellowish smeared on the counter top. Interview with staff revealed that no one went into R1's room when 911 was activated and R1 was taken to the hospital. Staff stated that R1's room is normally cleaned on a daily basis and weekly by housekeeping. (Continue on LIC9099...) Substantiated 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. Due to the pandemic, LPA only conducted a virtual tour of the facility on 10/30/2020 and was not able to observe the smell of R1's room. Interview with the staff revealed that R1 had a pet cat and cat food has a smell. However, staff stated that R1's room did not have a strong odor. 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. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Nov 18, 2021 · control 15-AS-20201022092629

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 19, 2021

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by having R1's room uncleaned which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2021

Plan of correction: LPA observed a new resident occupying R1's room and observed the room to be cleaned without odor. No POC needed. Deficiency cleared during inspection.

Type of visit: Case Management - Other

On 11/18/2021 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Executive Director, Bill Grady. While LPA was conducting a complaint investigation to deliver findings, the following deficiency was observed. LPA observed S4 was not associated to the facility or other sister facilities. 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, Nov 18, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(2) · Plan of correction due date: Nov 24, 2021

Criminal Record Clearance. Request a transfer of a criminal record clearance as specified in Section 87355(c) or... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not associated S4 to the facility which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2021

Plan of correction: Executive Director has agreed to submit LIC9182 and a copy of photo ID for S4 to CCLD by POC date.

Type of visit: Required - 1 Year

On 7/28/2021 at 11:05am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. LPA met with Executive Director, Bill Grady and Business Office Manager, Rachel Davis and explained the purpose of this visit.. During the Infection Control Inspection, LPA toured facility with Executive Director and Business Office Manager including but not limited to front entrance, screening station, hand washing stations, apartments, common areas, kitchen and courtyard. 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. Facility staff were observed to be wearing proper PPE. LPA observed 30-day supply of PPEs and accessible to staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 28, 2021