Terrace View Assisted Living

Allegation investigated: Staff mismanaged resident's medication

On 10/10/23 at 11:50AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM. During visit, the department obtained the following documents from administrator - staff roster, residents' roster, admission agreements, physicians reports, ID/Emergency information, hospital discharge reports, Centrally stored medication logs and Medication administration records Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff mismanaged resident's medication Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ADM) who stated she did not replace residents' prescribed medications with herbal supplements nor stop administering their prescribed & PRN medications. Review of R1 & R2's centrally stored medication logs and medication administration records dated 04/2023 until 10/2023 show staff assists both residents with taking prescribed and over the counter medications in accordance with physicians' instructions. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff mismanaged resident's medication and found it to be 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 that staff mismanaged resident's medication is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 15-AS-20231006135801

Type of visit: Case Management - Other

On 10/04/23 at 2:15PM, Licensing Program Analyst (LPA) conducted an unannounced case management visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM. LPA observed only two residents (R1, R2) are living at the facility. During visit, the department obtained the following documents from administrator - staff roster, residents' roster, admission agreements, physicians reports, ID/Emergency information, hospital discharge reports, Centrally stored medication logs and Medication administration records. Review of R1 & R2's centrally stored medication logs and medication administration records dated 04/2023 until 10/2023 show staff assists both residents with taking prescribed and over the counter medications in accordance with physicians' instructions. LPA observed both residents are diagnosed with dementia. ADM stated she administers each resident's medication as prescribed by their primary care physicians. ADM stated she did not replace residents' prescribed medications with herbal supplements nor stop administering their prescribed & PRN medications. Based on records review, interviews conducted, and observations made, the allegation that staff stopped administering prescribed medications to residents and replaced them with herbal supplements is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of report provided.the state’s words, verbatim · CDSS document, Oct 4, 2023

Type of visit: Required - 1 Year

On 07/19/23 at 9:30 AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 77 deg F. Hot water temperature was measured at 113 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Fire extinguisher was observed fully charged and purchased 05/26/23. Smoke and Carbon monoxide detectors were operational. LPA reviewed 2 staff and 2 resident files. LPA also conducted 2 staff and 2 resident interviews during visit. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/20/23:  LIC500- Personnel Report  Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 19, 2023

Type of visit: Required - 1 Year

On 07/20/2022 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct infection control inspection. LPA met with administrator and explained the purpose of the visit LPA toured the facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility staff were observed wearing masks. Facility has a 30-day supply of PPE maintained at a central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/22/22: · LIC500- Personnel Report · LIC308- Designation of Facility Responsibility · LIC610E- Emergency/Disaster Plan & Infection Control Plan · Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 20, 2022

Type of visit: Required - 1 Year

On 08/23/21 at 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed one staff wearing face mask during visit with one resident relaxing in living room with a face mask on. Facility has a completed mitigation plan in place dated 02/26/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Continued on next page LIC 809-C A written Emergency/Disaster plan dated 11/20/2020 was posted in a common hallway leading to the living room. Centrally stored medications were locked in kitchen cabinets. Sharp objects were locked in the kitchen drawers. Toxic chemicals were locked in the laundry room. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. Trash bins with lid operated with foot pedal were located inside bedrooms, bathrooms and kitchen. Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since February 2021.There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 73 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 08/31/2021: · LIC500- Personnel Report · LIC308- Designation of Facility Responsibility · LIC610E- Emergency/Disaster Plan · Evidence of Liability Insurance No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.the state’s words, verbatim · CDSS document, Aug 23, 2021

Allegation investigated: Licensee failed to safeguard resident confidential information.

On 8/17/2021 at 11:00AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the above allegations. LPA met with Manjula Michaelson, Administrator, and explained the reason for the visit. During investigation, the Licensee (S1), Reporting Party (RP), subject resident (R1) & one additional resident (R2) were interviewed; and the resident files for R1 and R2 were reviewed. The RP and S1 both had photos of a check from the RP and R1 that contained R1’s primary mailing address. S1 confirmed having shown this check to an unrelated third party. Continued from LIC9099C. Substantiated Continued from LIC9099. The Department has investigated this allegation and based upon interviews and records review, the allegation is Substantiated, meaning that the preponderance of evidence has been met. Deficiency cited per the California Code of Regulations, Title 22, Failure to correct the deficiency by the POC date may result in civil penalties. Exit interview conducted. Appeal rights and a copy of this report provided. Continued from LIC9099. The Department has investigated this complaint and although the allegations may have happened or are valid, there is not a preponderance of evidence that the allegations did or did not occur. Therefore, the allegations are Unsubstantiated. Exit interviewed conduct and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 17, 2021 · control 15-AS-20191028135815

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(3) · Plan of correction due date: Aug 24, 2021

1569.269 Enumerated rights; severability (a) Residents... shall have all of the following rights: (3)To confidential treatment of their records and personal information... This requirement was not met as evidence by: Licensee did not comply with the section cited above by keeping Resident's record confidential, which imposes a potential health and safety risk for person in care.the state’s words, verbatim · CDSS document, Aug 17, 2021

Plan of correction: Administrator agreed to submit a self-certification that the regulation has been reviewed and administrator will abide by the regulation. Self-certification will be submitted by the POC date.