Friendship Care Home

Allegation investigated: Facility withheld resident's personal belongings

On 11/08/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with manager on duty (MOD), gathered information and delivered investigation findings of above allegations. LPA explained the purpose of the visit with MOD. During investigation, the department obtained the following documents from manager on duty - staff roster, residents’ roster, admission agreement, physicians report, ID/Emergency information, hospice records, Safeguard of property & valuables form and incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Facility withheld resident’s personal belongings Investigation Finding: Substantiated During investigation, LPA interviewed staff (MOD) who confirmed that they withheld resident’s (R1) personal belongings from authorized representative (POA) around 1:40PM on 11/01/23 because POA refused to sign for R1's remaining personal items being collected that day which were a wall decor wreath, black IPad, photo album binder, rose colored floral twin quilted bedspread and eye glasses with red case. Review of incident report dated 11/01/23 showed R1's family members came to pick up R1's personal belongings around 1:40PM and became aggressive with staff (pushing staff against the front door, grabbing R1's personal items, yelling at staff) when they refused to sign the release form given by staff for R1's remaining personal items. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility withheld resident’s personal belongings was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Facility did not prevent resident's personal belongings from becoming damaged. Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff and reviewed resident (R1) documents. Staff (MOD) stated that when R1 passed away on 01/12/23, R1's family member collected her personal belongings inside her bedroom which were a cloth suitcase, photo albums, box of clothes, bible, black fanny pack, pillow, red IPad, rose bed sheet set. MOD stated she observed all items collected on 01/12/23 were in good condition and that the bible had no water damage. Review of R1's property & valuables form dated 01/12/23 showed R1's listed personal items were released and signed by staff and R1's family member that day with no written observation of damage to any of the items collected. During visit on 11/08/23 at 1:45PM, LPA observed R1's remaining personal items (wall decor wreath, photo album, black IPad, eye glasses in red case and twin quilted bedspread) were not damaged and kept locked inside the facility's office for safekeeping. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility did not prevent resident's personal belongings from becoming damaged and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility did not prevent resident's personal belongings from becoming damaged is unsubstantiated.the state’s words, verbatim · CDSS document, Nov 8, 2023 · control 15-AS-20231102093631

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(j)(2) · Plan of correction due date: Nov 30, 2023

The executor or the administrator of the estate shall be notified by the licensee, and the cash resources, personal property, and valuables surrendered to said party. This requirement was not met as evidenced by staff withholding resident’s personal belongings to authorized representative on 11/01/23.the state’s words, verbatim · CDSS document, Nov 8, 2023

Plan of correction: By POC due date, administrator agreed to complete and submit in-service staff retraining certificates on how to properly safeguard & surrender residents’ personal belongings & valuables in compliance with Title 22 Section 87217(j)(2).

Allegation investigated: Facility staff not treating for scabies at facility

On 10/05/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit, met with manager on duty (MOD), gathered information and delivered investigation finding of above allegation. LPA explained the purpose of the visit with MOD. During investigation, the department obtained the following documents from manager on duty - staff roster, residents roster, admission agreement, physicians report, ID/Emergency information, centrally stored medication logs, medication administration records, public health and incident reports. Allegation: Facility staff not treating for scabies at facility Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ADM) who stated that resident (R1) was initially sent to the hospital on 09/04/23 due to low blood pressure & oxygen. R1 returned from the hospital on 09/08/23 with new medications. ADM stated staff noticed R1 itching on 09/10/23 and consulted with his health care team who stated it could be his medications side effect. On 09/30/23, R1 was again sent back to the hospital due to a change in condition (weakness). Continued on next page, LIC 9099-C Unsubstantiated The hospital evaluated R1 and confirmed he had scabies on 10/02/23. ADM immediately contacted local public health and implemented infection control plan. ADM stated all residents’ linens and clothing were hot water washed and cleaned on 10/03/23. Additional staff was hired to implement infection control. ADM stated all staff and residents were evaluated for scabies and only one resident (R2) displayed itching. ADM stated R2 is scheduled to see his doctor on 10/06/23 for evaluation & treatment. ADM stated R1 is scheduled to come back from the hospital on 10/05/23. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility staff are not treating for scabies and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility staff are not treating residents for scabies is unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 5, 2023 · control 15-AS-20231003161047

Allegation investigated: Questionable Death Staff did not ensure that resident was adequately fed Staff prevented residents from having visitors Staff did not ensure that residents grooming needs were met Facility staff does not answer the telephone

On 06/30/23 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM. Allegation: Questionable Death Investigation Finding: Unsubstantiated During investigation, IB investigator reviewed resident’s (R1) medical records from 07/01/2022 to 08/15/2022. Staff stated they found R1 unresponsive during their rounds at approximately 1330 hours on 08/06/22. Staff immediately called 911 and initiated CPR on R1. Paramedics arrived at approximately 1345 – 1400 hours and stabilized R1 who was transported to ER hospital and admitted on the same day at approximately 1413 hours. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Questionable Death Investigation Finding: Unsubstantiated Continuation from page 1 R1’s chief complaint was cardiopulmonary arrest. R1 was pronounced deceased at the hospital approximately 1425 hours on 08/06/22. Review of R1’s Death Certificate show cause of death was Cardiovascular Disease. 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 resident’s death was questionable due to neglect/lack of supervision by staff is unsubstantiated. Allegation: Staff did not ensure that resident was adequately fed Investigation Finding: Unsubstantiated During investigation, staff (ADM) stated that R1 was a very picky eater and always ate breakfast daily. ADM stated R1 did not want to eat lunch and dinner at the facility since his admittance on 06/01/22. ADM stated she notified R1’s authorized representative (POA) about R1’s refusal to eat lunch and dinner. ADM stated staff offered him protein drinks (Boost) which he often refused. Review of weekly meal plans and random interviews with residents (R2, R3, R4) confirm they are fed three meals a day plus snacks by staff with a variety of meats, fruits and drinks. 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 did not ensure that resident was adequately fed is unsubstantiated. Allegation: Staff prevented residents from having visitors Investigation Finding: Unsubstantiated During investigation, staff (ADM, S1) confirmed with LPA that residents were allowed to be visited at the facility. Staff, residents and visitors were screened at the front entrance for COVID infection control. ADM stated they encouraged residents’ families and visitors to make an appointment prior to the visit. Review of visitors logs show staff allowed visits by family, friends and other agencies at the facility. 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 prevented residents from having visitors is unsubstantiated. Allegation: Staff did not ensure that residents grooming needs were met Investigation Finding: Unsubstantiated During investigation, staff (ADM, S1) stated that resident (R1) was showered and groomed twice a week (Tuesdays & Saturdays PM) by staff. Review of weekly shower schedule show residents’ shower frequency each week. LPA also interviewed random residents (R2, R3, R4) who confirmed that staff assisted them with their activities of daily living (bathing, grooming, dressing, toileting). 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 did not ensure that residents grooming needs were met is unsubstantiated. Allegation: Facility staff does not answer the telephone Investigation Finding: Unsubstantiated During investigation, LPA observed staff (ADM, S1) answered the facility phone when called on 08/19/22, 8/23/22 and 09/01/22. ADM stated the facility has a general phone number (925-732-7364) given for residents’ families/authorized representatives (POAs) to call and leave a message for staff to return call. ADM also stated they have a second phone line (925-303-2978) available for residents and families to use when necessary. ADM stated the fax number (925-732-7196) at the facility is a separate number from both phone lines and is not connected to any of the phone lines. 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 does not answer the telephone is unsubstantiated. Exit Interview conducted and a copy of this report provided. Allegation: Staff did not maintain a medication log for residents Investigation Finding: Unfounded During investigation, LPA observed facility staff maintain Centrally Stored medication logs and medication administration records on residents. LPA reviewed copies of resident’s (R1) Centrally Stored medication logs and medication administration records with prescription dates filled by local pharmacy from 04/05/22 to 06/15/23. LPA also reviewed random residents’ (R2, R3, R4) prescribed medication records during visit. This department had investigated the complaint alleging that staff did not maintain a medication log for residents. We have found that the complaint was unfounded, meaning that the allegation was without reasonable basis. Allegation: Staff overmedicated resident Investigation Finding: Unfounded During investigation, LPA reviewed resident’s (R1) Centrally stored medication logs and medication administration records dated 04/05/22, 06/10/22, 06/15/22, 06/21/22, 06/23/22 which showed R1 was not prescribed or administered any morphine by staff while at the facility. Staff (ADM, S1) stated they administered prescribed medications as ordered by the residents’ primary care physicians. Staff (ADM) stated R1 was not on hospice care and was not prescribed morphine by his doctor. This department had investigated the complaint alleging that staff overmedicated R1. We have found that the complaint was unfounded, meaning that the allegation was without reasonable basis. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 30, 2023 · control 15-AS-20220831093716

Allegation investigated: Staff did not safeguard resident’s belongings

On 06/30/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM. Allegation: Staff did not safeguard resident’s belongings Investigation Finding: Substantiated During investigation, staff (ADM) confirmed with LPA that some of resident’s (R1) personal belongings were missing in her room when family member collected R1’s belongings after R1 passed away on 01/12/23. Continued on next page, LIC 9099-C Substantiated ADM stated they later contacted authorized representative (POA) several times to pick up R1’s remaining misplaced personal items (wall décor wreath, Black IPad and photo album) left at the facility with no response from POA. 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) that staff did not safeguard R1’s belongings 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. Allegation: Resident developed pressure injuries due to staff neglect Investigation Finding: Unsubstantiated Continuation: On 01/03/23, R1 developed a new skin issue on her right heel (stage 1) and a redness on her left heel. On 01/10/23, the right heel wound developed into a stage II/III pressure injury. Staff implemented hospice care instructions on how to offload pressure on heels. On 01/11/23, hospice care team nurse observed the right heel pressure injury was a stage 1. Blister was wrapped in a kerlix and there was redness on the left heel. No new skin issue was noted by hospice nurse. 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 resident developed pressure injuries due to staff neglect is unsubstantiated. Allegation: Staff did not provide adequate assistance to resident in a timely manner Investigation Finding: Unsubstantiated During investigation, IB Investigator confirmed with Home Health and Hospice care team that R1 was on Home Health and Hospice Care from 06/10/22 to 01/12/23. Review of hospice records show that R1 received care and supervision by hospice care team (RN, LVNs, NP) while in hospice care. Staff (ADM, S1, S2) stated they implemented R1’s hospice care plan as instructed by the hospice care team. 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 did not provide adequate assistance to resident in a timely manner is unsubstantiated. Allegation: Staff did not get resident’s representative’s permission prior to performing a medical procedure on resident while in care Investigation Finding: Unsubstantiated During investigation, staff (ADM) stated that staff implemented hospice care instructions on how to offload pressure on R1’s heels by elevating her feet with foam or pillow supports. ADM stated that any invasive medical procedure on R1 was performed by the hospice care team only. Review of hospice records show hospice team notified and updated R1’s family / primary caregiver and primary care physician regarding R1’s condition on 12/29/22, 01/03/23, 01/10/23, 01/11/23 and 01/12/23. 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 did not get resident’s representative’s permission prior to performing a medical procedure on resident while in care is unsubstantiated. Allegation: Staff did not communicate with resident’s representative regarding resident’s change in condition in a timely manner Investigation Finding: Unsubstantiated During investigation, staff (ADM) confirmed with LPA that R1’s authorized representative (POA) was updated on R1’s change in condition while in hospice care. Review of hospice records show hospice care team notified and updated R1’s family / primary caregiver and primary care physician regarding R1’s condition on 12/29/22, 01/03/23, 01/10/23, 01/11/23 and 01/12/23. 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 did not communicate with resident’s representative regarding resident’s change in condition in a timely manner is unsubstantiated. Allegation: Staff did not turn resident as necessary Investigation Finding: Unsubstantiated During investigation, staff (S1) stated that they followed resident’s (R1) hospice care plan as instructed by the hospice nurses. Review of R1’s hospice records dated 01/11/23 show R1 had no new skin issues noted, blister on right heel (currently wrapped in kerlix) and redness on left heel. Staff (S1) stated that R1 was not on a turning scale schedule because R1 can still turn on her own. 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 did not turn resident as necessary is unsubstantiated. Allegation: Staff did not accord resident dignity Investigation Finding: Unsubstantiated During investigation, staff (ADM, S1, S2) denied verbally abusing resident (R1) while in care at the facility. LPA interviewed random residents (R2, R3, R4) who stated that staff treat them well and do not call them names. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore that staff did not accord resident dignity is unsubstantiated. Allegation: Staff did not maintain medical equipment in a sanitary manner Investigation Finding: Unsubstantiated During investigation, staff (ADM) confirmed with LPA that resident (R1) had dedicated use of medical equipment while in care. ADM stated that staff followed resident’s (R1) hospice care plan as instructed by the hospice nurses and sanitized medical equipment as prescribed by the hospice care team. 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 did not maintain medical equipment in a sanitary manner is unsubstantiated. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 30, 2023 · control 15-AS-20230228130610

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jul 14, 2023

Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff… This requirement was not met as evidenced by R1's misplaced personal belongings at the facility which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Jun 30, 2023

Plan of correction: By POC due date, Administrator agreed to complete and submit to CCL in-service staff retraining certifications on safeguarding residents' cash resources and personal belongings in compliance with Title 22 Section 87217. Administrator stated POA and Ombudsman were both notified regarding R1's remaining personal belongings that need to be picked up at the facility.

Type of visit: Required - 1 Year

On 06/30/23 at 3PM, 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, hand washing stations, 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, 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 30-day supply of PPEs, paper, medications locked in medication room cabinets. Comfortable temperature was observed at 77 deg F per thermostat reading. Hot water temperature was measured at 116 deg F. Fire extinguishers were last inspected on 01/05/23 and observed fully charged. 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. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. LPA also conducted 3 staff and 3 resident interviews during visit. The following deficiencies were observed during inspection: Automatic front gate damaged Insufficient food supply in the kitchen (not enough for census of 31 residents) Broken kitchen vents Lifting flooring between Shower 2 entry and hallway Peeling walls in Shower #2 Continued on next page, LIC 809-C Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 07/03/23:  LIC500- Personnel Report  Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Deficiencies are 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.the state’s words, verbatim · CDSS document, Jun 30, 2023

Allegation investigated: Staff mishandled the residents medication records

On 05/16/23 at 12:45PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator and delivered investigation finding. LPA explained the purpose of the visit with administrator. During investigation, LPA reviewed random 6 residents' (R1, R2, R3, R4, R5, R6) centrally stored medication logs with corresponding medication administration records for April & May 2023. LPA observed facility is meeting regulations for medication records perTitle 22 Sections 87465 and 87506. This department had investigated the complaint alleging that staff mishandled the residents medication records. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. Nothe state’s words, verbatim · CDSS document, May 16, 2023 · control 15-AS-20230509104128

Allegation investigated: Facility did not provide authorized representative a copy of resident's records

On 03/14/23, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with manager on duty (MOD) and spoke with administrator (ADM) who authorized MOD to act on her behalf and sign the reports. LPA explained the purpose of the visit with ADM and MOD. LPA conducted interviews, gathered information and delivered investigation finding to MOD and ADM. During visit, LPA confirmed with MOD that facility received Fed Ex package containing the request for copies of resident's (R1) records from authorized representative on 03/03/23. MOD stated she sent the Fed Ex package to ADM on 03/07/23. ADM confirmed with LPA during visit that she did not provide authorized representative a copy of R1's records. Continued on next page, LIC 9099-C Substantiated 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) that facility did not provide authorized representative a copy of R1's record is 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.the state’s words, verbatim · CDSS document, Mar 14, 2023 · control 15-AS-20230313084925

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(01) · Plan of correction due date: Mar 17, 2023

All information and records obtained from or regarding residents shall be confidential. (1) ... The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by facility not providing authorized representative a copy of resident's records which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Mar 14, 2023

Plan of correction: By POC due date, ADM agrees to send authorized representative coplies of R1's records and submit to CCL proof of submission.

Type of visit: Case Management - Health Checks

On 03/07/23 at 11:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving a priority 2 complaint. During the health and safety check, LPA observed a total of 6 staff wearing face masks and 31 residents at the facility. LPA toured facility with manager on duty, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 7, 2023

Allegation investigated: Licensee did not issue a refund

On 11/04/22 at 10:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with administrator (ADM) and spoke with licensee (LC) on the phone. LPA explained the purpose of the visit with ADM and LC. Based on record reviews and interviews, resident (R1) was admitted at the facility on 08/06/22 under hospice care. ADM confirmed R1's authorized representative (POA) made timely monthly payments for R1's care and supervision per signed admission agreement. On 09/26/22, R1 passed away at the facility and his personal belongings were removed on the same day. Continued on next page, LIC 9099-C Substantiated LC confirmed with LPA that a refund check was issued to POA by mail dated 10/15/22. LPA observed issuance of the refund check was 5 days past the 15 day refund period when R1's personal belongings were removed (09/26/22) from the facility. LPA discussed refund check total with LC based on the remaining 9 days total refund due to POA for the month of September 2022. On 11/04/22, LC issued another refund check of $45 payable to POA as full and final payment of R1's September 2022 refund. 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.the state’s words, verbatim · CDSS document, Nov 4, 2022 · control 15-AS-20221027103728

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(A) · Plan of correction due date: Nov 4, 2022

Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652 This requirement was not met as evidenced by late refund of R1's paid September 2022 when R1 passed away on 09/26/22 which was in violation of Title 22 Section 87507 refund regulation.the state’s words, verbatim · CDSS document, Nov 4, 2022

Plan of correction: Administrator corrected deficiency during visit. Final refund check of $45 sent to R1's POA dated 11/04/22. Licensee and administrator understood Title 22 Section 87507 and will comply with Admission agreement regulations including refund policies.

Allegation investigated: Facility did not adhere to the admission agreement requirements

On 10/07/2022 at 11:15 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct complaint investigation for the above allegation. LPAs met with Supervisor, Esmeralda Vega and explained the purpose of the visit. LPAs spoke to Administrator over the phone and Administrator is not available. During the complaint investigation, LPAs interviewed staff and reviewed records. Based on interview with S1 and record review of resident's Admission Agreement, there is a non-refundable policy regardless of removal of the resident's personal property upon after a resident's death. However, it is in violation of Title 22 regulation 87507(g)(5)(A). REPORT CONTINUES ON 9099C Substantiated Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation IS found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 7, 2022 · control 15-AS-20220929165630

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(A) · Plan of correction due date: Oct 14, 2022

87507(g)(5)(A) ADMISSION AGREEMENT (5) Refund conditions.(A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. This requirement is not met as evidenced by: Based on record review and interview, the Licensee did not comply with the regulation cited above by stating there is a non-refundable policy which poses a potential personal rights to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2022

Plan of correction: By POC date, Administrator will amend admission agreement in accordance to regulation and submit a copy to CCL.

Allegation investigated: Residents are being locked inside the facility. Staff are not adhering to COVID-19 infection control

On 10/07/2022 at 11:15 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct complaint investigation for the above allegation. LPAs met with Supervisor, Esmeralda Vega and explained the purpose of the visit. LPAs spoke to Administrator over the phone and Administrator is not available. During the course of the investigation, LPAs toured facility, reviewed records, collected documents and interviewed staff and residents. It was alleged residents are being locked inside the facility. Based on information obtained, staff were looking for the key to the front main entrance and visitors were unable to leave facility. At 12:45 PM, LPAs observed a key attached to the door. S1 and S2 stated that staff keeps the front main entrance locked so residents who are diagnosed with dementia cannot leave the facility. REPORT CONTINUES ON 9099C Substantiated It was alleged facility staff are not adhering to COVID-19 infection control. Based on information obtained , facility sometimes does not screen visitors and does not have them sign the sign-in log. Based on observation at 11:35 AM, LPAs observed a visitor was not screened and did not sign the sign-in log. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal rights and a copy of this report provided. It was alleged staff did not assist resident's needs at night time. No forthcoming information from resident 1. However, based on interview with 5 residents, 5 of 5 stated that staff assists them in the evening when they need assistance. It was alleged facility did not maintain adequate temperature for the resident's room. LPAs observed room temperature for both wings are set to 77 degrees F in the right wing and 76 degrees F in the left wing. LPAs interviewed 5 residents and 5 of 5 stated they have no issue with their room temperature. S1 stated when the HVAC was in disrepair last year, all residents affected were provided a fan in their rooms. It was alleged staff are providing care and supervision while under the influence of alcohol or drugs. However, based on interview with 5 staff and residents, 5 of 5 staff and 5 of 5 residents stated they have not observed staff being under the influence of drugs or alcohol while providing care. It was alleged lights in resident's room is in disrepair. Based on observation, lights in R1's room is in disrepair. However, S1, S2 and S3 stated that R1 was provided a lamp. LPA was unable to prove or disprove allegation. It was alleged facility did not issue resident a refund. R1 was admitted to the hospital on 9/21/22. Based on information obtained by reporting party, R1's family member decided to not have R1 return to the facility. S1 and S2 stated resident did not want to return to the facility. LPAs reviewed R1's records and did not observe an eviction notice was issued to R1. LPAs discovered during a record review that there is a no refund policy regardless of how many days a resident stayed. 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 with Supervisor.the state’s words, verbatim · CDSS document, Oct 7, 2022 · control 15-AS-20220930151105

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Oct 7, 2022

87568.1(a)(6) 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: (6) To leave or depart the facility at any time and to not be locked into any room, building.... This requirement is not met as evidenced by: Based on observation and interviews, Licensee did not comply with the regulation cited above by locking front main etrance door with a key which poses an immediate personal rights to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2022

Plan of correction: By POC date, Administrator will review regulations, cease locking the exterior doors, and submit a self-certification letter to CCLD. In addition, Administrator will conduct staff training and submit a copy of training agenda with staff signatures.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Oct 7, 2022

87405(d)(2) ADMINISTRATOR - QUALIFICATIONS AND DUTIES (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the regulation cited above by visitor was not screened and requested to sign in which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2022

Plan of correction: By POC date, Administrator will review PIN 22-28-ASC and conduct in-service training with staff, and submit a copy of training agenda with staff signatures to CCLD.

Type of visit: Case Management - Deficiencies

On 10/07/2022 at 11:40 am, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen conducted a Case Management while at the facility for complaint (CN# 15-AS-20220930151105 and CN# 15-AS-20220929165630). LPAs met with Supervisor, Esmeralda Vega and explained the purpose of the visit. LPAs spoke to Administrator over the phone and Administrator is not available. THE FOLLOWING DEFICIENCIES WERE OBSERVED: At 11:40 AM, LPAs observed ottoman blocking an exit door. There are 3 beds and wheel chairs obstructing another exit door. At 3:20 PM during record review, R1 was admitted to the hospital for spitting out blood. However, an incident report was not submitted CCLD. S1 confirmed an incident report was not submitted. 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, Oct 7, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Oct 10, 2022

87307(d)(6) PERSONAL ACCOMODATIONS AND SERVICES (d)The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the regulation cited above by storing items blocking the exit doors which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2022

Plan of correction: By POC date, Administrator will remove items and submit a photo to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Oct 14, 2022

87211(a)(1) REPORTING REQUIREMENTS (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above by not submitted an incident report for R1 which poses a potential heatlh and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2022

Plan of correction: By POC date, Administrator will review regulation and submit a self-certification letter (LIC 9098) to CCLD

Type of visit: Case Management - Health Checks

On 09/01/22 at 2:31PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving a priority 1 complaint. During the health and safety check, LPA observed a total of 6 staff members and 33 residents at the facility. LPA toured facility with administrator, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 1, 2022

Allegation investigated: Facility staff did not dispense medication as prescribed Licensee did not maintain current record of resident’s medications

On 08/23/22 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with administrator, gathered information, conducted interviews and delivered investigation findings of above allegations. LPA explained the purpose of the visit with administrator. Allegation: Facility staff did not dispense medication as prescribed Investigation Finding: Unfounded Based on interviews and record reviews, resident (R1) confirmed with LPA during visit that he refused all the prescribed medications from his doctor because he did not feel like taking them on 08/01 and 08/02. As a result, he experienced shortness of breath and chest pains on 08/03, sent to the hospital by staff for evaluation/treatment and was released back to the facility the same day with no changes to his baseline. Thus, the allegation that facility staff did not dispense R1's medication as prescribed is unfounded. Continued on next page, LIC 9099-C Unfounded Allegation: Licensee did not maintain current record of resident’s medications Investigation Finding: Unfounded Review of resident's (R1) medication administrator records dated 08/01/22 to 08/31/22 show R1 had 10 prescription medications (Clonidine, Atorvastatin, Amlodepine, Gabapentin, Lisinopril, Omeprazole,Valproic Acid,Zinc Oxide,Stool softener, aspirin) and 1 PRN (Acetamenophin) administered and signed by staff on a daily basis. Thus, the allegation that licensee did not maintain current record of R1's medications is unfounded. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Aug 23, 2022 · control 15-AS-20220817172538

Type of visit: Prelicensing

On 07/08/22 at 1:10PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct a Change of Ownership Pre-licensing Required inspection. LPA met with Applicant/Administrator and explained the purpose of the visit. The facility currently has 31 residents. LPA toured facility including but not limited to 35 apartments with dedicated bathrooms, kitchen, common areas and backyard. LPA observed COVID signages posted at the front entrance, common areas, sinks, bathrooms. LPA observed screening station at the front desk with no touch temperature probe, hand sanitizers, additional face masks, visitors logs. COVID infection control plan (LIC 9282) was observed complete. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 75 degrees F and hot water temperature was maintained at 112 degrees F. First-aid kit was observed to be complete. Medications, sharps and disinfectants/chemicals were observed locked. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 06/04/22. Pre-licensing is complete and there are no deficiencies observed during visit. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. Exit interview conducted and a copy of this report was provided to Applicant via email.the state’s words, verbatim · CDSS document, Jul 8, 2022

Type of visit: Case Management - Other

On 07/08/22, while at the facility for another reason, Licensing Program Analyst (LPA) completed the Component III presentation with applicant and discussed the most common deficiencies for RCFEs and how to avoid common pitfalls. Applicant agreed to comply with all RCFE Title 22 regulations and will ensure staff complies with all requirements in a timely manner.the state’s words, verbatim · CDSS document, Jul 8, 2022

Type of visit: Case Management - Other

On 06/16/22 at 3:30PM, while at the facility for another reason, Licensing Program Analyst (LPA) D Panlilio discussed that there was no unusual incident report (LIC 624) submitted on 06/03/22 to CCLD reporting there were 4 COVID positive residents on that day. 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.the state’s words, verbatim · CDSS document, Jun 16, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Jun 24, 2022

Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate This requirement was not met as evidenced by absence of LIC 624 on incident which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Jun 16, 2022

Plan of correction: By POC due date, administrator agrees to submit to CCLD self certification that staff has read and will comply with Title 22 Section 87211 reporting requirements.

Type of visit: Prelicensing

On 06/16/22 at 1:40PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced pre-licensing visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM. LPA observed 3 staff wearing face masks during visit. COVID-19 screening station is at the front desk where no touch temperature probe, visitors logs, additional face masks, hand sanitizers and gloves are available for visitors, residents and staff. LPA observed 7 residents not wearing face masks in the visitation areas. ADM stated that they encourage them to wear face masks but they refuse while inside the facility. Antigen mass testing were completed on 06/06 & 06/10 by ADM & floor supervisor to all residents and staff. Test results were all negative. ADM stated CC Public Health cleared facility yesterday, 6/15/22 of COVID infection. LPA requested ADM to email a copy of CC Public Health clearance from ADM during visit. LPA toured the facility with ADM and observed the following deficiencies: Insufficient food (2 day perishables and 1 week non-perishables) in the kitchen pantry, refrigerators and freezers Insufficient staff - Current staffing (AM shift 3 caregivers, floor supervisor & administrator M- F; PM shift is 2 caregivers, one Med Tech, one activity & cook staff: NOC shift 1 caregiver & 1 Med Tech). One resident (R1) requires one on one care. Common hallway in the east wing has laminated flooring that is peeling Common bathroom flooring in the east wing is deteriorating Broken blinds inside residents' bedrooms and common hallway doors Warm temperature inside facility - thermostat reading at 82 deg F Continued on next page, LIC 809-C Pre-licensing is incomplete with deficiencies to be resolved by 07/16/22. A follow-up Pre-licensure LIC 809 will be generated upon resolution of deficiencies. 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.the state’s words, verbatim · CDSS document, Jun 16, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(a) · Plan of correction due date: Jun 17, 2022

General food service requirements The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by insufficient perishable and non perishable food in the kitchen pantry which posed an immediate health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Jun 16, 2022

Plan of correction: By POC due date, administrator agreed to submit to CCLD copies of purchase receipts for perishable & non-perishable foods sufficient to meet residents' needs.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Jun 17, 2022

Personnel Requirements Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by insufficient staff to meet residents' needs which posed an immediate health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Jun 16, 2022

Plan of correction: By POC due date, administrator agreed to hire additional staff sufficient to meet residents' needs.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 15, 2022

Maintenance & Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by deteriorating floorings, warm temperature and broken window blinds which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Jun 16, 2022

Plan of correction: By POC due date, administrator agreed to submit to CCLD proof of corrections for repairs to deteriorating floorings, broken window blinds and warm temperature to ensure the health & safety of residents are not compromised.