Cherish Care Home

Type of visit: Case Management - Incident

On 10/19/2023 Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 10/06/2023. LPA L. Alexander met with Caregivers, Kimarley Whyte and Symone Reeves and explained the purpose of the visit. LPA L. Alexander asked if the Resident #1 (R1) was still residing at the resident. Kimarley says that the resident moved out on 10/06/2023. Kimarley says that the resident went back to the hospital a second on 10/06/2023 and was discharged but they do not know where the resident went to next. LPA L. Alexander received an e-mail and had a conversation with Licensee/Administrator, Ogedi Okeigwe, regarding the incident that 911 was called due to breathing issues that R1 was having and that he felt that R1 needs a higher level of care in which the caregiving staff is unable to give. Furthermore, the exception request for the PEG-Tube in which R1 had was also withdrawn. LIC809C....Continued.... LIC809....Continued The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Oct 26, 2023

87224 Eviction Procedures The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) Based on observation, review and interview the licensee did not comply with the section cited above by following appropriate eviction procedures o R1 which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator/Licensee shall review the regulation and submit self-certification that they read and understand the regulation moving forward to CCLD by POC Due Date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87637(a) · Plan of correction due date: Oct 26, 2023

87637 Health Condition Relocation Order (a) If a resident has a health condition...Department shall order the licensee to relocate the resident. Based on observation, review and interview the licensee did not comply with the section cited above by assisting the relocation of R1 to another care facility which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator/Licensee shall review the regulation and submit self-certification that they read and understand the regulation moving forward to CCLD by POC Due Date.

Type of visit: Required - 1 Year

On 08/30/2023 at 11:06 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Kimarley "Marley" Whyte and explained the purpose of the visit. The Licensee/Administrator, Ogedi Okeigwe, arrived approx. 12:30 PM. The facility’s fire clearance was approved for 6 Non-Ambulatory, of which 1 can be Bedridden and approved hospice waiver for 2. LPA toured facility with Marley including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 6 bedrooms are occupied by the residents. Staff resides in cottage off in the back area. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 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 116.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/06/2023. Emergency Disaster Plan was last posted on 07/23/2020. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/07/2023. LIC809C...continued LIC809 Continued.... At 12:00 PM, LPA reviewed 6 residents records in which 1 of the resident had recently passed. At 1:00 PM, LPA reviewed 5 staff records and 4 of 5 have current first aid training and associated to the facility. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 12:15 PM, LPA observed during record review and interview that R1 has a prohibited health condition. 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. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/06/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 30, 2023

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

During investigation of complaint (Complaint Control # 15-AS-20210511161656) and upon checking of facility roster and the Department’s Guardian Portal for fingerprinted and associated individuals, the Department learned that staff (S1) was fingerprinted but not associated to this facility. On this day, November 16, 2022, Licensing Program Analyst (LPA) Delmundo arrived to the facility unannounced and met with staff, Kimarley Whyte. LPA informed the purpose of visit. LPA called and spoke with Ogedi Okeigwe, administrator, over the phone and informed of the above. Deficiency and plan and proof of correction were discussed with the administrator. Exit interview conducted. Appeal Right, LIC9098 Proof of Correction form and copy of this report provided to Kimarley White.the state’s words, verbatim · CDSS document, Nov 16, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(2) · Plan of correction due date: Nov 30, 2022

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). -This requirement is not met as evidenced by: -Based on interview and records review, the licensee did not comply with the section above for staff who is not associated to the facility which posed potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: The staff no longer works in the facilty. Administrator to read the Regulation and self-certify that in the future any individual prior to working will be associated. Self-certification to be submitted by 11/30/2022.

Type of visit: Required - 1 Year

On 9/8/2022 at 4:05PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Kimarley Whyte, Caregiver, and explained the purpose of the visit. Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, and kitchen. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 115.8 degrees Fahrenheit. Fire extinguisher last serviced on 1/5/2022. There is a minimum of 2-day perishables foods and 7-day non-perishables foods. During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the mitigation plan on file. LPA observed food and paper supplies are sufficient. Continued on LIC809C, Continued from LIC809. LPA request the following documents to be submitted to CCLD by 9/15/2022. LIC 9182 Infection Control Plan LIC 610E Emergency Disaster Plan A copy of Administrator Certificate LIC308 Designation of Responsibility LIC500 Personnel Record No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 8, 2022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Resident (R1) sustained pressure injury while in care.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the complaint findings for the above allegation. LPA met with Kimarley Whyte, and informed the reason for the visit. It was alleged that after 3 weeks of being admitted to the facility, resident (R1) developed stage IV pressure injury on the back that was septic. During the course of investigation, the Department obtained and reviewed R1’s medical records, and conducted interviews. .....continued next page (9099C) Unfounded Medical records showed that prior to admission to the facility, R1 had a fall in R1’s home with ongoing pain. R1 reported sudden onset of bilateral leg weakness where R1 was found with a new T11 fracture. R1 had a custom Thoracic Lumbar Sacral Orthosis (TLSO) brace that R1 was directed to wear any time R1 was not laying in bed. R1’s family member (FM) stated that R1 fell while R1 was living in R1’s home and R1’s vertebrae were shattered and had a surgery. FM stated R1 was given a brace to be worn all day and from rehab, R1 moved to the facility where R1 was seen by Home Health who provided wound care. Social Worker (SW) stated that R1 was admitted to the emergency, and after being seen by the doctor, was determined that R1 was septic due to a stage IV on R1’s lumbar spine. It was also determined that the TLSO brace was pressing on the area causing the pressure injury, and the hospital staff were sure that the pressure injury was caused by the brace. S1 and S2 stated that R1 wore the brace and only removed when sleeping which corroborated with R1’s statement. R1 indicated that the injury was not caused by neglect by staff but by the brace. Residents (R2 and R3) were interviewed who both confirmed that R1 had been wearing the brace which looked uncomfortable but R1 never complained of pain. Based upon records review and interviews, the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis, therefore, the complaint is dismissed. Exit interview conducted and a copy of report provided.the state’s words, verbatim · CDSS document, Aug 16, 2022 · control 15-AS-20210511161656

Type of visit: Required - 1 Year

On 12/01/2021 starting at 9:55 AM, Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with House Manager Kimarley Whyte and explained the purpose of the visit. Administrator Ogedi Okeigwe was unavailable and authorized Kimarley Whyte to sign off the report. Upon entry, LPA’s temperature was checked and Covid-19 questions were asked by the staff, requested to sign-in and wash hands. LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, common areas, and outdoor areas. There was 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. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of most PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 1, 2021

The state marks this report as 2 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 on call night staff.

On 8/13/2021 starting at 9:05am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with Care Staff, Renny Lumi. Back-up Administrator, Winifred Wepee later arrived at 9:25am. During the course of the investigation, LPA P. Singh conducted 10-day initial investigation on 12/19/2019. On 8/11/2021, LPA L. Francisco interviewed S1 over the phone and obtained and requested a copy of facility's Personnel Report (LIC 500) via email for October 2019 to December 2019. Based on record review, a night shift staff is scheduled to work from 7pm-7am. No forthcoming information provided by reporting party. 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, Aug 13, 2021 · control 15-AS-20191216134758

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.