A Beloved Home of Diamond Bar

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to caregiver Rio Basco and administrator MyMy Dong arrived shortly after and assisted with the visit. The facility is licensed for age range 60 and over. Non-ambulatory of which 1 may be bedridden. Hospice Waiver for 6. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Covid-19 Screening for visitor still in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirement: A current Plan of Operation at the facility is completed. Hospice waiver plan and dementia plan was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is for 6 non-ambulatory of which one (1) maybe bedridden. Currently, there's only one bedridden resident in the facility. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. 3. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, kitchen, four residents bedrooms, two resident's bathroom, staff break room, live in staff room, laundry room and attached garage. Bedroom#1 and #4 has two beds, two chairs, required furniture and beddings and sufficient lighting and closet space. Bedroom#2 and #3 has one bed, one chair, one night stand, drawers, required furniture and beddings and sufficient lighting and closet space. All two residents bathrooms have the required grab bar and non-skid mat. The bathrooms are clean, sanitary and in a good working condition. The hot water in both bathrooms were tested between 112.1 and 113.1 which is within the Title 22 regulation. (See LIC 809C for continuation) All knives and sharp utensils are stored in a locked box in kitchen drawer. All the cleaning solutions and chemicals are stored and locked in the overhead cabinet in the laundry room. The extra linen and personal hygiene products are stored and in the hallway cabinet. LPA inspected the carbon monoxide detectors are working properly. The passageway, patio and walkway are free of obstruction. 4. Staffing: The facility has sufficient number of staffing. The facility has at least one staff with CPR training. The night shift staff also received the facility emergency planned training and has an updated First Aid Training in place. 5. Personnel Record and Training: All the facility staff are over 18 years old, associated and fingerprint cleared with the facility. The administrator is My My Duong and her administrator certificate expiration date on 7/18/2024. All the staff has the required documents in their personnel files which includes: health screening, TB Test result, required training hours and updated first aid certificate. 6. Resident Record/Incident Reports: LPA inspected all three (3) resident files and they all have the required documents which include : face sheet, update physician report, TB test result, needs and service plan, admission agreement, medication record and pre-appraisal assessment. A death report/incident report blinder was reviewed. 7. Resident's Right: LPA observed the Long Term Care Ombudsman poster, CCL complaint poster and personal right in the living room. The facility would provide internet service with at least one internet access device for resident to have video conferencing with their family members if needed. 8. Planned Activities: The facility has a sufficient space to accommodate both indoor and outdoor activities was observed. 9. Food Service: Currently no resident is required modified diet prescribed by the physician. The facility has sufficient 2 days perishable and 7 days non-perishable food supply in the facility. All the food are stored properly. 10. Incidental Medical and Dental: LPA inspected three (3) resident medication. The medication is centrally stored and locked in the hallway cabinet. All resident's medication are seemed accurate and updated. All the residents have the 30 days supply of medication. Facility staff also provide transportation to resident medical and dental appointment if needed. 11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D) in place and its updated on 4/2/23. The last fire/earthquake/flood drill was conducted on 8/1/23, 9/1/23 and 10/1/23. The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training. 12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there's one resident on hospice and one on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. Half and full bed rails for mobility assistance were observed in resident rooms. No deficiencies were observed during the visit. Exit Interview Conducted. A copy of the report was provided to the administrator MyMy Duong.the state’s words, verbatim · CDSS document, Oct 13, 2023

Allegation investigated: Residents are not provided proper medication assistance.

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Genia Polistico/S-1 and explained the purpose for the visit. Elizah Arganosa (Administrator Assistant/S-3) arrived at approximately 9:45 A.M.. During this investigation, LPA obtained a copy of the resident and staff rosters, a copy of the menu and diet restrictions, reviewed files, medication and Medication Administrator Records (MARs) for Resident #1 through Resident #3 (R-1 through R-3) and obtained relevant documentation, conducted a facility tour, interviewed Staff #1 through Staff #3 (S-1 through S-3) and interviewed Resident #1(R-1) and Resident #3 (R-3). LPA was unable to interview R-2 as R-2 was resting at the time of this visit. Refer to LIC 9099C for the continuation of this report. Substantiated Allegation: Residents are not provided proper medication assistance. It is alleged that staff are making medication errors. LPA reviewed resident medications and the Medication Administration Records (MAR). It was discovered that (R-3) had the following over-the-counter medications without a physician’s order: Tussin DM Max, Stool Softener and Stimulant Laxative (Docusate Sodium 50mg Sennosides 8.6mg), Anti-Diarrheal (Loperamide HCI Tablets-2mg) and Antacid Maximum Strength. Per staff interviews, the medications listed above have been provided to R-3 as followed: Tussin DM Max was last administered on 08/23/23. Stool Softener and Stimulant Laxative (Docusate Sodium 50mg Sennosides 8.6mg) has been administered daily. Anti-Diarrheal (Loperamide HCI Tablets-2mg) was last administered 08/05/23. Antacid Maximum Strength last administered on 08/26/23. Medication review and staff interviews corroborates this allegation. Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC9099-D. An exit interview was conducted, a copy of appeal rights and this report was provided to Elizah Arganosa (Administrator Assistant/S-3). Allegation: Residents in care have access to centrally stored medications. It is alleged that resident's creams and ointments are being left accessible to residents. During the facility tour, LPA did not observe any medications being left accessible to residents. Per staff interviews, medications are centrally stored and locked inside the hallway cabinet. LPA observed the medications to be locked and inaccessible to residents. Staff indicated they have not received any complaints/concerns in regards to this matter. Per resident interviews, staff administer medication to residents. Per resident interviews, there are no medications kept inside their bedrooms. Interviews do not corroborate this allegation. Allegation: Staff do not ensure facility is kept clean. It is alleged that the facility is unclean and staff do not clean resident rooms regularly. During the facility tour, LPA observed this facility to be clean and well organized. Per staff interviews, this facility is cleaned and kept clean daily. Per staff interviews, the facility is deep cleaned (3) times per week. Additionally, staff indicated they dust, sweep, mop and take out the trash daily. Per staff interviews, they have not received any complaints/concerns in regards to the facility not being kept clean. Per resident interviews, staff clean this facility on a daily basis (including their bedrooms). Per resident interviews, they do not have any concerns regarding this matter. Interviews do not corroborate this allegation. Allegation: Staff do not provide proper incontinence care to residents in care. It is alleged that residents diapers are not being changed timely and cleaned correctly. Per staff interviews, staff provide proper incontinence care to residents in care in a timely manner and residents are cleaned correctly. Per staff interviews, staff conduct rounds frequently and attend to resident needs. Per staff interviews, all residents also have a call button to use when they need staff assistance. Staff indicated they have not received any complaints/concerns in regards to this matter. Per resident interviews, staff provide incontinence care to residents in a timely manner and staff clean residents correctly. Per resident interviews, they do not have any concerns regarding this matter. During the facility tour, LPA observed additional incontinence supplies for R-1 through R-3 stored inside the attached garage. Interviews do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Allegation: Staff are unable to communicate with residents in care. It is alleged that residents are having trouble with speaking to care staff due to a language barrier and not understanding English well, causing issues to arise. Per staff interviews, staff are able to effectively communicate with residents. Interviewed staff indicated they have not received any complaints/concerns in regards to communication. Interviewed residents indicated that staff are able to communicate with residents. Interviewed residents indicated they do not have any concerns in regards to this matter. Interviews do not corroborate this allegation. Allegation: Residents are not provided proper food service. It is alleged that the facility is not serving residents healthy meals. During the facility tour, LPA observed sufficient amount of food supply. There was a variety of nutritious foods available such as fresh fruits, vegetables, meats, eggs, milk ect.. LPA obtained a copy of the facility menu and resident's dietary restrictions. Both, the food menu and dietary restriction lists were observed to be posted on the refrigerator doors. Interviewed staff indicated the facility provides proper food service. Interviewed staff indicated they follow the menu and the residents’ dietary restrictions. Staff indicated residents receive (3) meals and snacks in between meals. Staff indicated they have not received any complaints/concerns regarding this matter. Resident interviews revealed that staff provide proper food service. Per resident interviews, staff provide (3) meals and snacks in between. Interviewed residents indicated they enjoy the food that is provided and do not have a concerns. Interviews do not corroborate this allegation. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. Per California Code of Regulations, Title 22, no deficiencies were observed or cited. An exit interview was conducted, a copy of appeal rights and this report was provided to Elizah Arganosa (Administrator Assistant/S-3).the state’s words, verbatim · CDSS document, Aug 29, 2023 · control 28-AS-20230821113645

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Aug 30, 2023

Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label of the medication This standard is not met as evidence by: R-3 had the following medications without a physician’s order: Tussin DM Max, Stool Softener and Stimulant Laxative (Docusate Sodium 50mg Sennosides 8.6mg), Anti-Diarrheal (Loperamide HCI Tablets-2mg) and Antacid Maximum Strength.the state’s words, verbatim · CDSS document, Aug 29, 2023

Plan of correction: Administrator to obtain a physician’s order for the medication referenced on this citation. Administrator to submit a written statement as to how staff will adhere to this regulation and provide it to LPA Irra by POC due date

Allegation investigated: Facility yard is hazardous.

Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial visit to investigate the above allegation. LPA met with My My Duong/Administrator and discussed the purpose of today's visit. During this investigation, LPA obtained a copy of the Resident and Staff Rosters, interviewed My My Duong/Administrator and conducted a tour of the front and back yards. Allegation: Facility yard is hazardous. Per interview conducted, Administrator was unaware that it was the facility's responsibility to have the brush (downhill towards the freeway) cleaned/maintained until the Administrator received a call from the Fire Department. Per Administrator, Administrator was under the impression that the City of Diamond Bar handles the brush cleaning (down the hill towards the freeway). Per Administrator, the clean up of the back yard/hill has been scheduled. Refer to LIC 9099C for the continuance of this report. Substantiated Based on LPA's interview and tour, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. Refer to LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided to My My Duong.the state’s words, verbatim · CDSS document, Jun 29, 2023 · control 28-AS-20230623154904

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 4, 2023

Maintenance and 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 is not met as evidence by: Administrator was unaware that it was the facility's responsibility to have the brush (downhill towards the freeway) cleaned/maintained until the Administrator received a call from the Fire Department.the state’s words, verbatim · CDSS document, Jun 29, 2023

Plan of correction: Administrator to have the brush cleaned and maintain it clean at all times. Administrator to submit a written statement as to how Administrator will comply with this regulation and provide proof of correction (pictures) to LPA Irra by POC due date of 07/04/23.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) V. Maldonado made an announced visit at the facility for the purpose of conducting the Pre-Licensing inspection. LPA Maldonado met with applicant My My Duong and explained the purpose for the visit. The facility is a one-story home, located in a residential area. The facility will be licensed to serve the elderly, ages 60 and over. It is approved for (6) non-ambulatory residents, of which (1) may be bedridden in room# 3 only, with an approved hospice waiver for (6) and a dementia care plan. The home consists of (5) bedrooms, (2) bathrooms, a kitchen, living room, dining room, laundry room, caregiver break room, a shaded patio in the back yard, and an attached garage. LPA conducted a tour of the physical plant with licensee My My Duong and observed the following: All resident bedrooms had the required furniture such as bedding, linens, closet, additional storage space, chairs, and lamps. Bedroom# 1 has a fireplace that is not in use and inaccessible by a fire screen. Both bathrooms had the required grab bars and non-skid mats. The water temperature was tested and measured at 108*F, which is within the required 105*F-120*F, per Title 22 Regulations. Additional linens were observed to be sufficient and in good condition. The laundry room was observed to be locked, with cleaning supplies/toxins/laundry supplies stored inside and inaccessible. The washer and dryer are operational and in good repair. There is a door at the end of the laundry room that leads to the garage. The garage will be used for additional storage and will remain locked and inaccessible to residents in care. The required signage was posted in the living room area, readily available for staff/residents/visitors to view. A copy of the Plan of Operations, Dementia Care Plan, and Hospice Waver Plan were maintained in the closet with the files. Auditory devices were observed at every entry/exit and were operational at the time of the visit. All entrances, exits, and walkways were observed to be free of debris, obstructions, and hazards. There are exit signs posted above every exit way in the facility and and signs with arrows pointing to the exit ways. The kitchen was observed to have the required food, flatware, utensils, and cups. (Report Continued LIC809-C...) All equipment in the kitchen was observed to be operational and in good repair. All sharps were observed to be in a drawer in the kitchen inside a lockbox. Staff/resident files were observed to be complete and will be maintained/locked in a closet in the hallway. Resident medications will also be centrally stored, locked and inaccessible in a hallway closet. The First Aid Kit, First Aid Manual, and emergency lighting were observed stored in the hallway closet where medications will be stored. The First Aid Kit had all of the required items such as bandages, gauzes, scissor, tweezers and a thermometer. The smoke/carbon monoxide detectors were observed to be interconnected and were tested and operational at the time of the visit. Several fire extinguishers were observed throughout the facility to be have recent inspections and be fully charged. An operating telephone was observed and was operational in the facility for resident use. During the pre-licensing inspection, LPA did not observe items which do not comply with applicable laws and regulations. Applicant My My Duong completed Comp III Orientation. The physical plant has been cleared. An exit interview was conducted, and a copy of this report has been provided to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAB Analyst.the state’s words, verbatim · CDSS document, Nov 18, 2022

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 COMP II Participant: My My Duong, Managing Member/Administrator Interview Method: Telephone interview On 11/8/22, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements/CPMB associations & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 8, 2022