Village Oaks Senior Care

Type of visit: Case Management - Other

Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Lavinia Muscan conducted a visit at Oak Hill Senior Care and met with Administrator Jennifer Hinch and explained the purpose of the visit. This report is being delivered at Oak Hill Senior Care for this facility. Based on records reviewed it has been determined that Licensee has an overdue license fee. This facility has an outstanding balance for fees due. The current amount owed is $3,339.00 and was billed on 5/3/2023. As of this date, the fees are overdue. LPA explained to Administrator that proof of payment and/or proof of payment plan needs to be provided to CCL by the date given. Per California Code of Regulations, Title 22 Division 6, Chapter 8, Type B deficiency is being cited today in violation of California Code of Regulations and follows on 809-D. Exit interview conducted and appeal rights provided. Report left at Oak Hill Senior Care.the state’s words, verbatim · CDSS document, Sep 5, 2023

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.185(a)(1) · Plan of correction due date: Oct 5, 2023

1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture (a)(1) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license … This requirement has not been met as evidenced by: Based on department's review of annual fees not being paid. This does not pose an immediate risk to residents.the state’s words, verbatim · CDSS document, Sep 5, 2023

Plan of correction: By 10/5/23, the licensee shall contact Community Care Licensing to pay the entire fee due. Failure to correct shall result in civil penalties.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lavinia Muscan arrived on Wednesday June 21, 2023 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (4) and staff files (3). All resident files contained the required paperwork. Staff file contained the required paperwork. Staff has current first aid and CPR training. Facility was clean and well organized. All required posting were observed. LPA and Administrator Jennifer Hinch toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. The administrator's certificate is current. There is a gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to Administrator.the state’s words, verbatim · CDSS document, Jun 21, 2023

Allegation investigated: Facility administrator lacks current qualifications. Facility does not have back up food supplies. Facility does not ensure that residents are adequately fed. Facility staff does not ensure that residents receive medications on time. Administrator does not spend a sufficient amount of time at the facility.

On 4/26/2023, Licensing Program Analysts (LPAs) Lavinia Muscan and Melissa Parks arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Rod Fleeman. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Facility administrator lacks current qualifications. Administrator does not spend a sufficient amount of time at the facility. During the course of the investigation, LPAs reviewed administrator qualification, staff time sheets, and obtained copies of facility documentation. The current facility administrator does have a valid administrator certificate, and certificates were obtained prior to assuming the role as administrator. Facility documents show that the Administrator is at the facility every day and as needed. Documents also show there is sufficient staff at the facility to meet the residents needs. Based on staff interviews and the information received, LPAs find the above allegations to be UNFOUNDED meaning that the allegation are false, could not have happened, and/or are without a reasonable basis. Facility does not have back up food supply. Facility does not ensure that residents are adequately fed. During the course of the investigation, LPAs observed the food supply area and refrigerators. The facility has shown to have adequate amounts of 2 days of perishable foods and 7 days of non-perishable foods for residents. Interviews with residents revealed that the residents get additional servings during meals if requested and snacks throughout the day. Therefore, the finding for these allegations is UNFOUNDED meaning that the allegations are false, could not have happened, and/or are without a reasonable basis. Facility does not ensure that residents have medications on time. LPAs have reviewed medications, interviewed 5 staff and interviewed 2 residents. At this time, LPAs are not able to prove that there are any medications missing from the facility. Residents interviewed report receiving medications as prescribed. Medication counts appear to be accurate in relation to MAR. At this time, LPAs find no credible evidence that staff failed to properly administer resident's medications. Medications appear to be given as prescribed. Therefore, the allegation is UNFOUNDED meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Administrator Rod Fleeman and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 26, 2023 · control 25-AS-20220909161911

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) K.. Hiratsuka, arrived at the facility unannounced to conduct an unannounced annual visit using the infection control tool visit. LPA met with Facility Administrator Ron Fleeman, and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they used hand sanitizer shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Caregiver. LPA and Administraror toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time. A couple of topics were discussed. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facilitythe state’s words, verbatim · CDSS document, Jul 14, 2022

Allegation investigated: Staff administered medication to resident not prescribed by a physician Staff did not seek medical attention for resident

Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore a mask and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Rod Fleeman. Witness observed a notation on a MAR that was crossed out and noticed the resident was reportedly lethargic. No observable reaction or hospitalization. Resident was on hospice and on other narcotic medication. No direct witness that these allegations occurred. The identified party adamantly stated that the medication was never administered to the wrong resident, it was merely charted under the wrong resident and crossed out at the time of notation . Based on this, the allegation is UNSUBSTANTIATED. As a result of this investigation, LPA finds the allegation that staff administered medication to resident not prescribed by a physician and staff did not seek medical attention for resident to be 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 1, 2021 · control 25-AS-20210520151853

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: Food services are inadequate.

Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore an N-95 respirator and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Tanya Garcia. Visual inspection of 12 different food items, both perishable and non-perishable, were observed. None were expired. However, based on witness interviews, it was ascertained that residents were denied snacks upon request. This occurred usually, late at night or very early in the morning. According to the witnesses, this has not been a problem in the past several months, since the particular staff person, who denied snacks, no longer works at the facility. Based on this, this allegation is SUBSTANTIATED. As a result of this investigation, LPA finds the allegation that food services are inadequate to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Substantiatedthe state’s words, verbatim · CDSS document, Jul 29, 2021 · control 27-AS-20201103143012

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(3) · Plan of correction due date: Jul 26, 2021

87555-General Food Service Requirements- Between meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. This requirement is not met as evidenced by: Based on witness interviews, licensee did not allow snacks to residents upon request. This is in violation of this section. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2021

Plan of correction: Facility shall allow resident's to have snacks upon request. The staff member who violated this section, no longer works at the facility. ***Deficiency cleared during visit.

Allegation investigated: Resident developed pressure injuries while in care. Resident's toileting needs are not being met. Staff rough-handle resident in care. Facility is malodorous.

Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore an N-95 respirator and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Tanya Garcia. Allegations: Resident developed pressure injuries while in care. R1 was hospice when the complaint came in. Green Valley Hospice was the provider and notes from 10/25/20- "No pain or discomfort at this time. Peri and coccyx drg intact. No other skin issues." 11/25/20 indicate a "foul smell on coccyx area wound & drainage". 12/7/20- "No new skin issues noted. Dry". Physicians Orders 12/2/20- Coccyx - Cleanse with wound cleaner, pat dry, apply opticel to open area, cover with hydrocolloid or optifoam, or gentle sacrum 3 times a week or prn if soiled or dislodged". R1 while on hospice, may have or developed coccyx wounds. These issues were being actively addressed by the hospice care agency and were being treated and monitored by the hospice agency. R1 was on hospice and the ulcers are being actively treated and monitored. Based on this, this allegation is UNSUBSTANTIATED. Unsubstantiated Resident's toileting needs are not being met. Visual inspection of every occupied room (10) and none were malodorous and all appeared to be clean and tidy. All residents rooms had portable johns that were clean at the time of inspection. Staff stated that residents toileting needs are addressed on an as needed basis. Based on this, this allegation is UNSUBSTANTIATED. Staff rough-handle resident in care. Complaint states that an employee allegedly "mistreats" residents by pushing them to hurry them to bed. Interviews of residents and family members. Family members state that residents have never reported being pushed or rough handled. Family had nothing but praise for the care facility and the care that they have been providing. Family has no complaints about the facility. Based on this, the allegation is UNSUBSTANTIATED. Facility is malodorous. Visual and olfactory of every occupied room (10) and none were malodorous. All appeared to be clean and tidy. Staff stated that the only time the room would be malodorous would be if the occupant had used the portable john or had a recent bowel movement in their briefs at which time staff would immediately address the source of the odor. Based on this, this allegation is UNSUBSTANTIATED. As a result of this investigation, LPA finds the allegation that resident developed pressure injuries while in care, residents toileting needs are not being met, staff rough-handle resident in care and facility is malodorous to be 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.the state’s words, verbatim · CDSS document, Jul 29, 2021 · control 27-AS-20201103143012