Gabriel's House 1

Type of visit: Annual/Random

On 07/13/23 at 10:52 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Jane Bernardino, Licensee 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. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, 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 purchased in May 2023. At 11:32 am LPA reviewed 5 residents records. At 12:25 pm, LPA reviewed 5 staff records and 5 of 5 were fingerprint cleared and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 13, 2023

Allegation investigated: Staff restrained resident

On 03/10/2023 at 09:05 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings for the complaint investigation for the above allegation. LPA met with Amabelle Amparo, Caregiver and explained the purpose of the visit. During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. Based off interview’s, LPA confirmed that R2 was trying to climb out the window and S3 was trying to prevent R2 from falling. 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 this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 10, 2023 · control 15-AS-20220505152444

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.

Allegation investigated: Staff failed to treat resident with dignity and respect Resident is not feeling safe at the facility

On 01/13/2023 starting at 01:02 pm, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Amabelle Amparo, Administrator and explained the purpose of the visit. During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. Based on interviews and record reviews the staff was assisting another resident with their nightly routine and asked R1 to leave the room so they could get ready for bed. Staff also stated that they have had many disscuions with R1 about not opening all of the doors for saftey reasons but R1 contiuned to do so. 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 this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 13, 2023 · control 15-AS-20220425092910

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.

Allegation investigated: Staff allowed resident to be exposed to chemicals

On 01/13/2023 starting at 01:02 pm, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Amabelle Amparo, Administrator and explained the purpose of the visit. During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. Based off interviews with staff they had a routine pest control visit at the facility that came without notice due to it being routinely scheduled each year. Staff stated that normally this company calls before arriving and the staff would instruct residents to stay inside and keep the windows and door closed., but they did not call and inform the facility that they would be there. Continued on 9099-C... Unsubstantiated ...Continued from 9099 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 this report provided.the state’s words, verbatim · CDSS document, Jan 13, 2023 · control 15-AS-20220615151842

Allegation investigated: Staff retaliated against resident

On 01/13/2023 starting at 01:02 pm, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Amabelle Amparo, Administrator and explained the purpose of the visit. During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. Based off intrviews and records reviews, LPA confirmed that R1 had made threataning coments to S1. S1 in fear made a call to the police to assist in the situation and they removed the resident for the facility to midigate the situation. 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 this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 13, 2023 · control 15-AS-20220615160447

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.

Allegation investigated: Facility does not have hot water.

Licensing Program Analysts (LPAS) Alicia Delmundo and Lori Alexander arrived unannounced to continue the investigation of the above allegation and close the complaint. LPAs met with Alberto Bernardino, co-administrator. It was alleged that facility does have hot water due to staff running the dishwasher on the time resident R1 uses the bathroom to take shower. During the course of investigation, LPA Delmundo reviewed residents' (R1, R2., R3, R4) files. LPAs conducted interviews and tested the hot water temperature in common bathroom use by residents. LPA also checked the water heater which is a 50 gallon unit. ....continued 9099C Unsubstantiated During 2 visits to the facility, LPA Delmundo tested the hot water temperature in the common bathroom used by R1 which measured at 120 and 112.2 degrees Fahrenheit. Staff were interviewed. According to the administrator, R1 wanted the water temperature raised above 120 degrees Fahrenheit. Admiinstrator stated that they can not raise the temperature beyond 120 as it will be out of Regulations range of 105 to 120 degrees Fahrenheit. S1 and S2 stated they run the dishwasher in the morning and afternoon but the facility never run of hot water. They both indicated that when there was a complaint about the hot water due to running the dishwasher, they stopped running the dishwasher while R1 is taking a bath. S3, S4 and S5 stated the facility didn't have incident of running out of hot water. Residents (R2, R3) stated the hot water temperature was alright when they take showers. R4 stated staff gives R4 warm sponge bath. Based on the information gathered, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No citation issued. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 21, 2022 · control 15-AS-20220204130956

Allegation investigated: Facility administrator yelled at resident.

On 08/11/2022 at 1:25 PM, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with Administrator Gladys Enriquez and explained the purpose of the visit. During the course of the investigation, LPA L. Francisco obtained information, collected documents, and interviewed residents and staff. Based on information obtained by complainant, facility administrator yelled at resident. However, S1 denied yelling at resident. During an interview with S1, LPA L. Francisco discovered resident approached S1 to talk to her while S1 was unloading groceries, and S1 told resident to wait. According to S1, since she was wearing a mask, she needed to increase the volume of her voice because resident has a hard of hearing. REPORT CONTINUES TO 9099C Unsubstantiated LPA interviewed 3 residents, 3 of 3 residents denied witnessing staff yelling at other residents. LPA was unable to prove or disprove allegation. 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.the state’s words, verbatim · CDSS document, Aug 11, 2022 · control 15-AS-20220228162201

Allegation investigated: Staff sprayed strong smelling chemicals outside resident's door.

On 7/27/2022 at 12:00 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with Care Staff, Celia Clet and LPA explained the purpose of the visit. Assistant Administrator, Gladys Enriquez later arrived at 12:48 PM. During the course of the investigation, LPA obtained information, interviewed staff and residents. Based on information obtained, Staff sprayed strong smelling chemicals outside resident's door. However, LPA discovered during an interview with 6 staff, 6 of 6 staff denied spraying strong smelling chemicals outside resident's door. REPORT CONTINUES ON 9099C Unsubstantiated According to staff interviews, 4 of 6 staff mixes the floor cleaner with water and opens the windows when they are mopping the floor near the residents rooms. LPA interviewed 3 residents, and 3 of 3 residents stated they are not bothered by the chemical smell. 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.the state’s words, verbatim · CDSS document, Jul 27, 2022 · control 15-AS-20220216122111

Allegation investigated: Facility staff did not respond to resident's call for assistance.

On 7/27/2022 at 12:00 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with Care Staff, Celia Clet and LPA explained the purpose of the visit. Assistant Administrator, Gladys Enriquez later arrived at 12:48 PM. During the course of the investigation, LPA obtained information, collected documents, interviewed residents and staff. Based on information obtained, facility staff did not respond to resident's call for assistance. However, S4 stated once she heard R1 yelling for help, S4 went to check on R1 followed by S5. LPA interviewed 3 residents and 3 of 3 stated staff responds to their call when they need assistance. 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, Jul 27, 2022 · control 15-AS-20220216155120

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.

Allegation investigated: Staff is retaliating against resident for complaining

On 7/27/2022 at 12:00 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with Care Staff, Celia Clet and LPA explained the purpose of the visit. Assistant Administrator, Gladys Enriquez later arrived at 12:48 PM. During the course of the investigation, LPA reviewed record, collected documents, interviewed staff and residents. It was alleged that staff is retaliating against resident for complaining. Based on information from complainant, R1 was threatened to be evicted. However, S1 denied threatening R1 with eviction. LPA interviewed 3 residents and 3 of 3 residents stated they have not heard of staff retaliating against residents. 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, Jul 27, 2022 · control 15-AS-20220304092319

Allegation investigated: Staff failed to provide adequate food service Staff failed to treat resident with dignity and respect

On 7/20/2022 at 9:20AM, Licensing Program Analysts (LPAs) G. Luk and J. Clancy-Czuleger arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPAs met with Administrator, Gladys Min Enriquez and informed her the reason for the visit. During the course of investigation, LPA G. Luk interviewed 3 residents, 3 staff, and 2 witnesses. LPA also reviewed documents including facility menu and physician's reports for 3 residents. Staff failed to provide adequate food service: Interview with residents and witnesses revealed that three meals are provided to the residents. Witnesses stated facility foods were home cooked, healthy, and no meals were missed. Interview with staff indicated that one resident cooks their own food and staff provides 3 meals for the other 2 residents. However, if any residents ask for food, staff will provide it to the residents. (Continue on LIC9099C...) Unsubstantiated Staff failed to treat resident with dignity and respect: Interview with witnesses revealed that staff are tentative and providing great care to the residents. Witnesses stated that staff are polite and have not witnessed any staff be rude or ignored a resident. Residents stated that staff are nice and not rude to residents. 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, Jul 20, 2022 · control 15-AS-20220103090834

Allegation investigated: Staff did not treat resident with dignity

On 07/20/2022 at 9:20 AM, Licensing Program Analysts (LPA), J. Clancy-Czuleger and G. Luk arrived unannounced to deliver complaint findings for the above allegation. LPA met with Gladys Enriquez, Administrator and explained the reason for the visit. During the course of the investigation, LPA Jill Clancy-Czuleger interviewed Administrator, 3 residents, and 2 staff. Both of the staff memebers and the administrator stated that if a resident was asking for assistants they would stop what they were doing to assist if the sistuation was safe to do so. If not they would ask the resident to wait. Staff stated that the floors are moped twice a day and did not remember an incident of ignoring a resident. Although the allegation 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 this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 20, 2022 · control 15-AS-20220509101844

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.

Allegation investigated: Facility restrooms were not made accessible to resident in care

On 06/24/22, Licensing Program Analysts (LPA) J Clancy-Czuleger conducted an unannounced subsequent visit and met with Licensee Jane Bernardino, to deliver the findings of above allegation. LPA explained the purpose of the visit with Licensee. Investigation Finding: UNFOUNDED During the course of the investigation, LPA Jill Clancy-Czuleger interviewed Administrator, 3 residents, 2 witnesses and 2 staff. In the interviews with staff and other residents, all stated that all three bathrooms can be used by all residents. RP stated that the third bathroom on the other end of the house was available to use. Continued on next page, LIC 9099-C Unfounded We have found that the complaint was unfounded, meaning that the allegation is without reasonable basis. Exit Interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Jun 24, 2022 · control 15-AS-20220328090710

Allegation investigated: Staff are intimidating resident

On 06/24/22, Licensing Program Analysts (LPA) J Clancy-Czuleger conducted an unannounced subsequent visit and met with Licensee Jane Bernardino, to deliver the findings of above allegation. LPA explained the purpose of the visit with Licensee. Investigation Finding: UNSUBSTANTIATED During the course of the investigation, LPA Jill Clancy-Czuleger interviewed Administrator, four residents, and two staff. In the interviews staff stated that they talk to each other in Tagalog. Interviews with other residents and their families state that the staff don’t always speak English, but they have not seen the staff laughing at the residents. Continued on next page, LIC 9099-C Unsubstantiated 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 is unsubstantiated. Exit Interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Jun 24, 2022 · control 15-AS-20220328123115

Allegation investigated: Staff refused to provide a meal to resident.

On 06/24/22, Licensing Program Analysts (LPA) J Clancy-Czuleger conducted an unannounced subsequent visit and met with Licensee Jane Bernardino, to deliver the findings of above allegation. LPA explained the purpose of the visit with Licensee. Investigation Finding: UNFOUNDED During the course of the investigation, LPA Jill Clancy-Czuleger interviewed Administrator and 1 resident, and 1 witness. In the interview R1 stated that the facility does not cook for her, she cooks for herself. R1 stated she is sensitive to different foods and smells and does not like what the facility staff cooks so she makes her own food. When asked if she has ever been denied meals R1 responded “no I make my own”. LPA witnessed R1 using the kitchen during the investigation. Continued on next page, LIC 9099-C Unfounded We have found that the complaint was unfounded, meaning that the allegation is without reasonable basis. Exit Interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Jun 24, 2022 · control 15-AS-20220503124141

Type of visit: Required - 1 Year

On 06/24/2022 at 08:55 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Licensee Jane Bernardino 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 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. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. The following deficiency was observed during the visit: At 9:32 LPA observed the fire extinguisher was purchased on 6/16/21 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 24, 2022

Allegation investigated: Resident was locked inside her room

On 05/12/22, Licensing Program Analysts (LPAs) D Panlilio and J Clancy-Czuleger conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegation. LPA explained the purpose of the visit with administrator. Based on interviews and record reviews, resident (R1) stated that on 10/31/2021, her bedroom door handle broke, could not get out of her room and ended up calling 911. LPA’s review of staff’s (S3, S5) incident report dated 10/312021 show that at 6:30PM that night, they opened the window and exhaust fan in the kitchen to lessen the smell of food while preparing their dinner. S3 stated that R1 got out of her room at 7:10PM and witnessed her place a towel against her door and slammed it. At around 7:40PM, S3 witnessed R1 get out of her room again and opened the doors angrily. Continued on next page, LIC 9099-C Unsubstantiated Staff stated R1 returned to her room and around 7:42PM started hitting the door and shouting hysterically for help while inside. S3 stated she went outside to look at her by the window to check on how she was doing. S3 stated she went back to R1’s door again and heard R1 call someone on the phone. S3 stated she opened R1’s door and left R1’s door open while she called the administrator at 8PM to report the incident. At 8:15PM, staff stated a police officer came as well as the emergency responders (EMT). Staff stated R1 refused to leave the facility with EMT and told them she was OK and safe. Staff denied locking R1 inside her room. 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 is unsubstantiated. Exit Interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, May 12, 2022 · control 15-AS-20220511145824

Allegation investigated: Staff is disrupting resident's sleep

On 05/12/22 at 5:13PM, Licensing Program Analysts (LPAs) D Panlilio and J Clancy-Czuleger conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator. Based on interviews and record reviews, staff (S1, S3, S5) confirmed with LPA that during meal breaks they reheat food at the facility at various intervals. Resident (R1) is sensitive to smell and has complained to staff that her sleep is disrupted due to the pungent smell of food coming from the kitchen which is adjacent to her bedroom. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. 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. Substantiated Allegation: Staff locked resident out of the house Investigation Finding: UNSUBSTANTIATED Based on interviews and record reviews, staff (S1) stated that resident (R1) would go out on walks or run errands. LPA’s review of R1’s progress notes dated 11/05/2021 stated that staff (S4) saw R1 outside the facility door and reported that she was locked out at the other facility where she resides and could not get inside. Staff (S4) stated she accompanied R1 back to the facility, found the door unlocked , opened the door and let R1 inside the facility. S4 witnessed R1 talk to staff (S2). 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 is unsubstantiated. Allegation: Staff is harassing resident Investigation Finding: UNSUBSTANTIATED Based on interviews and record reviews, staff (S3, S5) denied harassing resident (R1). Interviews conducted by LPAs with other residents confirm staff do not yell or harass them. Interviews with staff (S1, S3, S5) denied harassing R1. 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 is unsubstantiated. Allegation: Staff withholds residents’ mail Investigation Finding: UNSUBSTANTIATED During investigation, staff (S1) stated that all residents’ mails are distributed by staff daily. S1 stated there was only one occasion wherein resident’s (R1’s) letter was found to be inadvertently inserted in the weekly supermarket advertising magazines which was overlooked. Upon discovery, staff immediately handed the letter to R1. S1 stated there was no intention to withhold any mail from any resident and have instructed staff to go through all magazines to ensure it will not happen again. Interviews with other residents confirm they receive their mail from staff. 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 is unsubstantiated. Exit Interview conducted and a copy of this report provided via email. Allegation: Facility is in disrepair Investigation Finding: UNSUBSTANTIATED During investigation, LPA toured the facility with staff (S3, S5, S6) on 12/14/2021. LPA observed the facility clean, in good repair and odor free. LPA also observed common refrigerator in the kitchen had R1’s food containers with sticky notes stored inside along with other residents’ food. Administrator also showed LPA the new refrigerator purchased for R1 so she can store her food separate from the other residents. 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 is unsubstantiated. Exit Interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, May 12, 2022 · control 15-AS-20211213165524

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 27, 2022

Personal Rights Residents in all residential care facilities for the elderly shall have all of the following personal rights (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination This requirement was not met as evidenced by staff disrupting resident's sleep due to reheating food during meal breaks which posed a potential health & safety risk to resident in carethe state’s words, verbatim · CDSS document, May 12, 2022

Plan of correction: By POC due date, administrator agreed to submit to CCLD proof of correction of completed in-service staff retraining on residents’ personal rights.

Type of visit: Case Management - Deficiencies

On 05/08/2022 at 9:15 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with staff Belle Ampero. Administrator Albert Bernardino arrived and joined later. 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.the state’s words, verbatim · CDSS document, May 8, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: May 30, 2022

Admission agreements shall be signed and dated, ... no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Based on observation and interview, licensee failed to ensure that a completed Admissions Agreement is placed in the record file of R1.the state’s words, verbatim · CDSS document, May 8, 2022

Plan of correction: Licensee shall arrange a meeting with R1 and/or R1's representative to complete all pages of an Admissions Agreement. Licensee shall submit copy of completed Admissions Agreement, dated and signed licensee, resident and/or resident's representative, to CCLD by POC date 5/30/22

Allegation investigated: Facility staff lacks training.

Licensing Program Analyst (LPA) Alicia Delmundo arrived unannounced to deliver the findings on the above allegation. LPA met with Jane Pabustan Bernardino, administrator, and informed the purpose of visit. On August 11, 2021, LPAs Alicia Delmundo and Catherine Lin obtained copies of LIC500 Personnel Report and staff training records. LPA Delmundo reviewed staff (S1 and S2) files and training records. S1 and S2 started working in this facility 5/26/2021 and 5/27/2021 and completed only 28 hours and 20 hours of training respectively. LPA verified and Jane Pabustan confirmed that S1 ans S2 have not completed the required 40 hours of training. ....continued next page (9099C) Substantiated Based on information obtained, the preponderance of evidence has been met, therefore the allegation is found to be substantiated. Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and plan and proof of correction were discussed with Jane Pabustan Bernardino. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. Based on the information obtained during the course of investigation and due to LPA unable to obtain information from one of the residents, the allegation of facility staff (S1) yells at resident (R1) is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, No deficiency cited. Exit interview conducted and copy of this report provided to Jane Pabustan.the state’s words, verbatim · CDSS document, Oct 21, 2021 · control 15-AS-20210802095819

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(a)(b)(1) · Plan of correction due date: Nov 4, 2021

§1569.625 Staff training; legislative findings; contents : (a)(b)(1)....require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member......shall be completed within the first four weeks of employment. -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section cited above for not having S1 and S2 complete the required hours of training which poses potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2021

Plan of correction: Administrator to have the staff complete the training and submit proof by 11/04/2021.

Type of visit: Case Management - Incident

On 07/16/2021 at approximately 9:44am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a case management visit regarding a self-reported incident that occurred on 06/06/2021. LPA met with Administrator, Jane Bernadino and explained the purpose of the visit. During the visit LPA spoke and reviewed incident with Administrator. Administrator stated that facility was responsible for notifying hospice agency when Resident R1's medications need a refill. On 06/04/2021 the facility contacted R1's hospice agency notifying agency that R1 would need a refill of seizure medication by 06/05/2021 in the afternoon. On 06/04/2021 R1 was no longer receiving hospice services and medications had been sent to R1's medical provider. The facility then contacted R1's medical provider on 06/04/2021, but the medical provider did not have the medication order. On 06/05/2021 R1 took R1's last pill of medication in the morning and the facility did not receive the medication until 06/06/2021. On 06/06/2021 R1 had a seizure. The following deficiency was cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or 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, Jul 16, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Jul 19, 2021

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interview and record review Licensee did not comply with the section cited above. Facility reached out to Resident R1's medical provider when R1 had one pill left which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2021

Plan of correction: Administrator agrees to create a policy for medications to be refilled at least ten days prior to medications running out and send a copy of policy to CCL by POC date.