Agnes House

Type of visit: Case Management - Annual Continuation

On 04/27/2023 at 3:45 PM Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Case Management - Annual Inspection. Upon entry, LPA disclosed the purpose of the visit with staff. At approximately 4:00 PM, Administrator (ADM) Gladys Enriquez arrived. During inspection, LPA reviewed staff and resident files. 1 Type B citation was issued (refer to LIC809-D for details). Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Apr 27, 2023

Type of visit: Required - 1 Year

On 04/26/2023 at 12:30 PM Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Required Annual Inspection. Upon entry, LPA disclosed the purpose of the visit with staff. At approximately 1:00 PM, Administrator (ADM) Alberto Bernardino arrived. During inspection, LPA inspected the physical plant inside and outside, the kitchen, and reviewed facility files. 1 Type B citation was issued (refer to LIC809-D for details). Additionally, Advisory Notes - Technical Violation (LIC9102) was issued for Licensee to replace the current Yard Sketch of the facility that accurately depicts the facility grounds and structures. Additional visit will be required to complete annual inspection. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Apr 26, 2023

Allegation investigated: Facility staff did not follow COVID-19 protocols.

On 02/10/2023, Licensing Program Analyst (LPA) J. Sampair arrived unannounced at 2:43PM to conduct a complaint investigation of the allegation above. The LPA met with Gladys Enriquez. During the investigation, the LPA conducted interviews of 3 staff members and 2 witnesses. Based on the interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Two (2) citations were issued (refer to LIC 9099D). Exit interview conducted and copy of this report provided via email. Substantiatedthe state’s words, verbatim · CDSS document, Feb 10, 2023 · control 15-AS-20230208084824

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 17, 2023

87468.1 PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews, the licencee did not comply with the section cited above, which poses a potential Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 10, 2023

Plan of correction: Administrator shall: (1) obtain all supplies necessary for adhering to the current COVID-19 protocols AND (2) training all staff members in all aspects of those COVID-19 protocols in accordance with PIN 23-02-ASC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Feb 17, 2023

87211 REPORTING REQUIREMENTS (a) Each licensee shall furnish reports as the Department may require ... (2) Occurrences, such as epidemic outbreaks which threaten ... health of residents ... within 24 hours This requirement is not met as evidenced by: Based on interviews, the licencee did not comply with the section cited above, which poses a potential Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 10, 2023

Plan of correction: Administrator shall complete and send copy of LIC624 to the Oakland Regional Office by fax or email.

Type of visit: Case Management - Other

On 02/10/2023, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced complaint investigation. The LPA met with Assistant Administrator Gladys Enriquez. During his inspection, the LPA discovered that the current facility Administrator is not at the facility an adequate amount of time each week for which they were cited (refer to LIC 9099D). Exit interview conducted and copy of this report provided via email.the state’s words, verbatim · CDSS document, Feb 10, 2023

Allegation investigated: . Lack of care and supervision resulting in wound on resident 2. Staff failed to assist resident with toileting in a timely manner 3. Staff failed to treat resident with dignity. 4. Staff speaking inappropreatly to residents. 5. Facility failed to meet reporting requirements.

On 8/4/2022 at 1:30PM, Licensing Program Analyst (LPA) J. Sampair and Licensing Program Manager (LPM) H. Humpal arrived unannounced to conduct a complaint investigation and delivered findings for the allegation above. LPA met with staff member Leamae "Mae" Jovellanos and informed her of the reason for visit. Administrator was notified of the visit by staff. Over the course of the investigation, LPA interviewed 4 staff and 2 residents and reviewed resident and facility records, including staff logs. - On 6/5/2022, R1’s private caregiver observed blood on R1’s bedsheet. Based on staff log notes, night staff did not note any bleeding or injuries for R1. S1 stated and provided photos showing that the bleeding was from a scab on R1’s lower leg at the sock level that did not require medical attention and was cleaned once staff became aware. R1 was no longer at the facility. Based on staff interviews and a review of care logs, photos, and videos, there was nothing showing a lack of care and supervision that resulted in the deterioration of the resident's physical condition. Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099-C - R1’s file was reviewed and other resident and staff was interviewed. Based on the information obtained, there is not sufficient information to indicate if staff assisted R1 with his/her toileting needs in a timely manner. - LPA interviewed total of 3 residents, R2’s private caregiver, and staff in question was interviewed. There were no issues residents raised in regard to staff not treating them with dignity. - Interviews with current residents did not indicate that they speak inappropriately to residents. Staff denies the allegation. - LPA reviewed daily staff logs and staff stated, no incident report was generated since it was minor scab to the skin which did not require any medical attention or concern. Based on the interviews conducted and the records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur. Exit interview with staff member Mae Jovellanos was conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 4, 2022 · control 15-AS-20220622145935

Type of visit: Required - 1 Year

On 04/27/2022 at 8:15AM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with S1 upon entry, who then called the administrator who arrived at 9:30AM. Facility has a mitigation plan (LIC 808) in place dated 07/09/2021 to mitigate the spread of COVID-19. LPA discussed the importance of having an updated infection control plan in accordance with PIN 22-13-ASC. LPA inspected the facility inside and outside. LPA observed the 2 staff assisting 6 of the 6 clients with activities of daily living. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. COVID-19 signs were posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. A written Emergency/Disaster plan was posted on the bulletin board for staff, clients and visitors to read. Centrally stored medications were locked in the cabinets. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were stored in a locked closet inside the garage. Infection control designated leader is the administrator. Continued on next page LIC 809-C All staff and 6 clients have been fully vaccinated. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the pantry and garage. Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged. Smoke and Carbon monoxide detectors were operational. Adequate supplies of PPE were also observed stored on the premises. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/05/2022: · LIC500- Personnel Report · LIC308- Designation of Facility Responsibility · LIC610D- Emergency/Disaster Plan · Evidence of Liability Insurance & Surety Bond Facility cited with 1 Type A and 2 Type B deficiencies, both of which were corrected during the visit. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Apr 27, 2022