A Faithful Home of Rossmoor

Allegation investigated: Staff locked resident in their room. Staff administered medication that was not prescribed to resident.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the two allegations listed above. LPA was greeted and granted entry by facility staff after stating the reason for the visit. House Manager Rudy Ignacio was notified of the visit via telephone and arrived later to assist with the visit. An initial complaint investigation visit was conducted on August 8, 2023. A tour of the facility's physical plant was conducted along with a review of resident records and an interview with the administrator. A follow-up visit was later held on August 25, 2023 with 4 staff interviews completed. Additional witness interviews were also conducted via telephone during the investigation. A total of five resident interviews were finally attempted or conducted during the present visit. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff locked resident in their room, the following has been concluded: Based on observation made in the physical plant, records reviewed and interviews conducted, LPA could not sufficiently evidence that any of the facility's door were equipped with a lock or a locking latch at the time of the allegations. Staff, witnesses and residents interviewed denied any knowledge of a resident ever being locked in their room. The allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did occur. Regarding the allegation that Staff administered medication that was not prescribed to resident, the following has been concluded: Based on evidence gathered, medication reviewed, records reviewed and interviews conducted, it could not be sufficiently evidenced that medication belonging to another resident was at any point administered to another resident for the purpose of managing their behavior. All medication observed during the three site visits were prescribed to a resident currently admitted and verified as such. However, in the presence of a photograph of medication on which the label had been marked off with a marker, the Department could not sufficiently ascertain that the allegation did not occur either. As a result, the allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did occur. A Technical Assistance Advisory Note is however issued to remind licensee that per Title 22 Regulations "No persons other than the dispensing pharmacist shall alter a prescription label". An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Oct 25, 2023 · control 22-AS-20230804111101

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of documenting a deficiency observed during the investigation of complaint 22-AS-20230804111101 at the facility. LPA had been greeted and granted entry by facility staff after introducing himself and the reason for the visit. Administrator Theresa Kholoma was notified by telephone and arrived later to assist with the visit. LPA went over the deficiency observed and provided a consultation on resident records as three recent admission agreements were observed to be missing an administrator signature. One Type B deficiency is cited on the attached form LIC809-D. A Technical Assistance Advisory Note is also issued regarding the Admission Agreements. An exit interview was conducted and a copy of this report along with appeal rights were provided to facility representative via email due to printer technical difficulties.the state’s words, verbatim · CDSS document, Aug 8, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Aug 9, 2023

The California Code of Regulations Section 87608(a)(5)(B) on Postural Supports states: "(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care(...)." This requirement is not met as evidenced by: Based on observation and interview, full rails were shown to be equipped on the bed of resident R1, who is not receiving hospice care at the time of the visit. This constitutes a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2023

Plan of correction: Licensee stated the bed rails had been equipped on the hospital bed when it was delivered at the facility, however resident does not actually need bedside postural support. The full rails were removed during the visit. Citation cleared during the visit.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Amy Morales the purpose of the inspection and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 02/02/2023. This is an initial application with no residents in care. During the inspection, LPA and AP observed the following: Structure. This is a one-story home. Facility is a 6-bedroom, 3-bathroom, 1 story house with detached garage that is being used for storage. There is a back yard with a patio cover for the residents. Facility telephone number is (562) 296-8164. Resident Bedrooms. The 5 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each resident bedroom inspected. Staff Bedrooms. The 1 staff bedroom is spacious and will easily accommodate the staff’s furnishings. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 117.6 and 118.2 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers and Exit Plan: Reviewed. Food Service. 7 days nonperishable food supply reviewed and AP stated they will obtain 2 days perishable food supply prior to accepting residents. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: will be locked in the garage until a lockable space is created inside the house. Toxins: will be locked in the garage until a lockable space is created inside the house. Medication will be locked in the garage until a lockable space is created inside the house. First-Aid Kit: observed and available. Resident & Staff Files. This is an initial inspection and LPA observed storage space for resident and staff files. Fire clearance was approved by Orange County Fire Authority on 04/27/23. Backyard. Backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. AP will obtain liability insurance once the application is approved. During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.the state’s words, verbatim · CDSS document, Jun 7, 2023

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Theresa Kholoma, Applicant; Alicia Munroe Administrator Interview Method: Telephone interview On May 23, 2023, Applicant/Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/ administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & 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, May 23, 2023

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Theresa Kholoma, Applicant/Administrator Interview Method: Telephone interview On May 4, 2023, Applicant/Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/ administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & 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, May 4, 2023