Aldersly

Type of visit: Office

An Informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager (LPM) Kimberley Mota, Licensing Program Analyst (LPA), Caitlynn Felias, and Administrator/Executive Director, Shannon Brown, and Health and Wellness Director, Melanie Fenn. The purpose of the Informal meeting was to address an incident that occurred on 09/13/2023 where Resident 1 (R1) went missing during a community outing at approximately 12:45PM. R1 was found safe in a nearby neighborhood at approximately 7:45PM. Items addressed during today’s meeting: · Facility’s procedures regarding community outings, resident elopements and absence without leaves (AWOLs) · Staff Training for residents with dementia and elopements · Incident Report received by Community Care Licensing (CCL) on 10/16/2023. Incident Report received stated that Resident 2 (R2) eloped from the facility on 10/15/2023. R2 was found by local police approximately two blocks away from the facility. Facility made all notifications per regulation. Review of R2’s Physician Report and Care Plan indicated that they are unable to leave the facility unassisted (This deficiency has been cited, see LIC809D and LIC421IM, Regulation 87705(b)(2)). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **A Civil Penalty in the amount of $1,000.00 is being issued today due to a repeat violation of Regulation 87705(b)(2) within a 12-month period. (See LIC421IM).** Exit interview conducted. Copy of report, LIC809D, LIC421IM, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator/Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 18, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Oct 19, 2023

87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering... This requirement is not met as evidenced by: Based on documents reviewed, the Licensee did not comply with the section cited above. Resident 2 (R2) eloped from facility and was found 2 blocks away. R2’s Physician Report states they have dementia. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Licensee to submit a written plan of updated procedures for elopement prevention. Licensee to submit documentation regarding delayed egress doors and to conduct an In-service training with all care staff regarding Elopement Procedures by POC due date of 10/19/2023. In-service training to include the following: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 10/29/2023.

Type of visit: Required - 1 Year

At approximately 10:15AM, Licensing Program Analysts (LPAs) Felias and Rummonds arrived unannounced to conduct a 1 Year Required Visit, and met with Executive Director/Administrator, Shannon Brown. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPAs were informed that there were 34 residents in Assisted Living and Memory Care with 37 Independent Living residents for a total of 71 residents in care. LPAs were also informed that there were 21 staff members on-site. At approximately 10:30AM, LPAs reviewed the Facility's Staff Roster with Administrator and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 11:00AM, LPAs conducted a walk-though of the facility with Administrator and observed the following: Facility consists of multiple buildings for Assisted Living and Memory Care. Facility has an Extended Care unit which is a separate wing for Older Adults that require a higher level of care. Facility also has independent living units on the property. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 8 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected January 2023. Facility smoke detectors are hard wired and connect directly to the local fire station. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected November 2022 and January 2023. Facility's last fire drill was conducted on July 2023. At approximately 12:45PM, LPAs reviewed a sample size of 3 resident files. Resident Files were all found to be well organized, thorough and contained the required documentation. Continued on LIC809C Continued from LIC809 LPAs also followed up on a self-reported incident that was submitted to Community Care Licensing (CCL). incident Report 1: On 9/13/2023, CCL was verbally informed that the facility was searching for Resident 1 (R1) who had disappeared during a community outing to the local zoo. CCL received an update that evening stating that R1 had been located and was safe. Facility submitted an incident report on 09/15/2023 regarding the incident and made all appropriate notifications per regulation. LPAs discussed R1 with Executive Director, and reviewed documents. Per conversation with Executive Director, R1 was apart of a community outing to the zoo that consisted of 3 staff members and 5 residents. At approximately 12:30PM, facility staff took R1 and 3 other residents to the bathroom. Facility staff then provided the residents with lunch. At approximately 1:30PM, facility staff observed that R1 was no longer with the group when they were boarding the bus. Facility staff contacted zoo personnel and police to review security footage. Facility staff and police observed that R1 exited the zoo premises at approximately 12:45PM. At approximately 3:00PM, facility staff notified Executive Director and Health and Wellness Director of the situation who headed to the zoo's location to assist in the search. At approximately 7:45PM, R1 was found safe and unharmed in a nearby neighborhood. Since returning to the facility, R1 has been observed to be at their baseline. Facility conducted an inservice training reviewing dementia elopements and AWOLs. Facility has also implemented new procedures regarding community outings. Per review of R1's Physician's Report, they are unable to leave the facility unassisted or without staff supervision (This deficiency has been cited, see LIC809D, Regulation 87705(b)(2). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Facility provided LPAs with In-service training materials and documentation. Deficiency cited today for Regulation 87705(b)(2) has been cleared during today's visit. **An informal meeting has been scheduled for October 18th, 2023, between the Facility and the Department. LPAs unable to complete Annual visit. Annual Continuation visit to be conducted at a later date. Exit interview conducted. Copy of report, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 26, 2023

Allegation investigated: - Staff did not follow resident’s feeding plan.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Administrator Shannon Brown to deliver findings regarding the complaint allegation above. Regarding allegation Staff did not follow resident’s feeding plan. Per Reporting Party, on 12/29/2022 it was noticed that there was a full food tray wrapped up sitting next to resident (R1) who had difficulty swallowing and was on a feeding plan where they were to be given soft or liquid foods because R1 had difficulty swallowing and was supposed to be provided assistance with eating. Also, Reporting Party noticed that there was a care plan taped over R1's bed dated 11/10/22, with a different resident’s name. Based on confidential interviews conducted with facility staff on 4/6/23, it was revealed that their normal meal process is to provide residents with their meal tray that has their name on it, then they will leave them for residents to eat it and staff will return about an hour later to remove the tray. Per staff, R1 had private caregivers that helped feeding R1. However, based on confidential interviews conducted with private caregivers, feeding R1 was not their duty to perform because they were hired for companion only. Also, based on records review of hospice care plan dated 12/25/22, R1 have a regular diet plan on file, but R1 was fully dependent, required to get assistance with feeding due to them were unable to feed self and must be assisted or supervised throughout their meals. Therefore, the facility staff did not follow resident’s hospice care plan dated 12/25/2022 about resident’s feeding care needs. The preponderance of evidence standard has been met; therefore, the above allegation of resident’s care needs is not being met is found to be SUBSTANTIATED. Substantiated Continued from LIC9099A...Regarding the allegation of appropriate measures were not put into place for resident who was a fall risk. Per Reporting Party, R1 was found on the floor at least two different occasions by private caregivers after R1 had slid out of the bed, their head and shoulders on a mat and the rest of their body on the cold floor with no injuries reported. Staff were unaware that R1 had fallen because they were not checking on R1 as they should have due to R1 was a fall risk. Per Reporting Party, R1 had a fall risk bracelet on their arm, but at some point, somebody at the facility took that bracelet off and it was placed on a table. Staff had lowered R1’s bed the lowest that it could go to the floor, and mats were placed around R1’s bed to address R1's fall risk. Based on records review of facility communication log dated 12/26/22 at 5:16am and 12/30/22 at 8:29pm confirmed that R1 had an un-witnessed fall. On 12/26/22 at 5:16am, R1 was found by facility staff lying on their back on the floor next to their bed, but denies hitting their head, facility conducted assessment of the resident, no injuries or skin discoloration were noted, facility notified R1’s responsible party and hospice about the incidents. Also, bed was set to the lowest position and floor pads were placed. On 12/30/22 at 8:29pm, R1 was found by facility staff facing up lying on the floor on top of their pad next to their bed. R1 was assessed, no injuries were noted and was assisted back to bed by 3 facility staff, facility notified R1’s responsible party and hospice about the incidents. Per incident report, both incidents contributing factors were R1’s balance impairment, poor safety practices and history of falls. Per hospice records obtained dated 12/25/22, R1 had an anxiety and/or agitation problem that a goal was set to minimize them with medication regimen in place to prevent fall risk while agitated. Also, R1 was assessed as a fall risk person and both incidents were noted in hospice daily care notes. Facility staff was instructed to monitor R1, safety checks, bed safety. However, LPA reviewed incident and death report logs for resident (R1) who passed away on 1/4/23 which were not reported to CCL within 7 days of incident. This deficiency will be addressed in a case management for reporting requirements. During confidential interviews conducted with staff that works in the Health and Extended Care Center (Kronborg), upon arrival to this area, Wellness Director removes any fall risk bracelet from resident’s arms because all of them are considered fall risk due to their mobility limitations, and staff is set to conduct round checks every two hours and if any resident need help sooner, residents will pull their call light system and staff will respond to their call within minutes. LPA obtained call light system response for both incidents that confirmed that R1 was assisted within minutes after having falls. A finding that the complaint allegation appropriate measures were not put into place for resident who was a fall risk is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continue on LIC9099C... Continued from LIC9099C...There is an allegation that staff did not properly dispose of food. Per Reporting Party, on 12/29/2022 it was noticed that there was a full food tray wrapped up sitting next to R1. On 12/30/2022 the same plate of food was still in resident's room which posed a safety hazard since the food was probably spoiled by then. Based on records review of facility communication log dated 12/29/22 at 8:24pm R1 was observed asleep most of the shift, refused dinner, staff offered fluids, but only took sips from toothaches. According to facility Wellness Director, there is a chance that this incident could have happen because the staff are instructed to leave meal tray in resident’s rooms, then the facility staff will return to remove the trays in about an hour later, but if residents have visitors they won’t interrupt them and will come back later. Also, LPA conducted confidential interviews with private caregivers who were not able to provide any supporting information to determine if the incident could have happened at a certain date. Due to conflicting information obtained by LPA is unable to determine that the alleged violation had occurred. A finding that the complaint allegation Staff did not properly dispose of food is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation of staff did not administer medication(s) to resident according to instructions. Per Reporting Party, Hospice had written orders for the staff to give resident morphine when needed, but private caregivers noticed that facility staff were not giving R1 their morphine, when inquired with staff about it staff said no. Hospice then changed the morphine order from a “PRN” to “Q4” (given every 4 hours). Private Caregivers discovered that staff were not adhering to that order either. During confidential interviews with staff and private caregivers, it was confirmed that facility caregivers don’t have direct access to Morphine, only facility Med-techs so morphine was an issue because staff either did not have access to the computer to place orders or to administer this medication to residents. Although, facility communication log and Centrally Stored Medication and Destruction (CSMD) log all doses of medications were listed on the facility medication records to have been dispensed as ordered by the resident's Physician. Also, hospice records obtained dated 12/25/22 confirmed that there were no issues with medication administration, but a couple times R1 refused medications and there was an adjustment to this medication on 12/29/22 due to potential medication-related problems, including adverse effects, drug reactions and drug therapy currently associated with laboratory monitoring, as well as impact of disease state and the patient’s perception of side effects. On 12/30/22 there was a situation where hospice received a call from R1’s responsible party reporting that med-tech could not provide them with an answer to confirm that R1 was getting morphine every 4 hours for pain management. However, hospice called facility and spoke with same med-tech, who stated correct understanding of R1’s medication order and stated times as follow for that day: 6:15am, 10:15am, they will be given at 2:15pm and ongoing every 4 hours). LPA has determined and confirmed that although caregivers did not access to morphine medications, Med-technicians will have access, they will give R1 their prescribed medication as ordered by their Physician, and there was no indication that any dosage was missed or not administered properly by facility staff. A finding that the complaint allegations “staff did not administer medication(s) to resident according to instructions” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 21, 2023 · control 21-AS-20230126084215

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(7) · Plan of correction due date: Apr 22, 2023

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement has not been met as evidence by: Based on LPA’s records review and interviews with facility staff, the facility did not ensure that staff was assisting resident (R1) with their modified diet care plan as prescribed by their Physician. This poses an immediate health & safety risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2023

Plan of correction: Administrator agrees to immediately review resident’s files to ensure modified diets including feeding plan are provided per physician's order. Administrator will submit a written plan stating how the facility will ensure modified diets will be specifically followed to CCL by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Administrator Shannon Brown to conduct a case management visit to follow up and cite deficiencies discovered during complaint investigation. During today’s visit, LPA is following up on a death report received at CCL on 2/7/2023. Per death report, on 1/9/23 resident (R2) who resided in the independent living section of the facility. R2 was found outside in the bushes by another resident, who notified staff and they called Emergency Personnel that transported R2 to the Hospital. R2’s responsible party were notified. However, LPA inquired with San Rafael Police Department and it was revealed that law enforcement was not contacted about the incident. LPA was informed that 911 was contacted, LPA is requesting security guard contract including frequency of round checks conducted for the month of January 2023. However, this incident needs further investigation and review prior to make a final determination. LPA learned through records review and interviews with Health/Wellness Director that resident (R1) had two incidents of falls on 12/6/22 and 12/30/22 which were not reported to CCL within 7 days of incident. Also, death reports for R1 who passed away on 1/4/23 and R2 who passed away on 1/9/23 were not submitted to CCL until 2/7/23. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penaltiesthe state’s words, verbatim · CDSS document, Apr 21, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: May 1, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of two incidents involving R1 after falls that occurred on 12/6/22 and 12/30/22 which poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2023

Plan of correction: Administrator to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, contact an outside vendor to conduct training for staff involved on reporting requirements. Signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted by POC due date.

Allegation investigated: Staff are not providing resident's files to resident's authorized representaive.

At approximately 9:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a complaint investigation regarding the above allegation and met with Executive Director/Administrator, Shannon Brown, and Charge Nurse, Melanie Fenn. There is an allegation that Staff are not providing resident’s files to resident’s authorized representative. Based on records reviewed and interviews conducted, LPA observed that Resident 1 (R1) resided in the Independent Living area of the facility. Community Care Licensing (CCL) does not have jurisdiction to enforce regulations on that portion of the facility. LPA was unable to identify any deficiencies on the Assisted Living (AL) side of the facility where CCL does have jurisdiction. The allegation that staff are not providing resident’s files to resident’s authorized representative is UNFOUNDED. An allegation that is UNFOUNDED, means that the allegation was false, could not have happened and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Mar 9, 2023 · control 21-AS-20230302111949

Type of visit: Case Management - Incident

At approximately 11:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management – Incidents visit and met with Executive Director/Administrator, Shannon Brown, and Charge Nurse, Melanie Fenn. The purpose of the visit is to follow up on incident reports that were self-reported to Community Care Licensing (CCL). Incident Report #1/Death Report: CCL received an incident report from the facility on 1/10/2023. The incident occurred on 1/9/2023. The report stated that Resident 1 (R1) was found outside in the bushes by another resident. The resident notified staff who notified Emergency Personnel. R1 was transported to the hospital. Facility made appropriate notifications per regulation. On 2/7/2023, CCL received a death report for R1. LPA, Executive Director, and Charge Nurse discussed R1. R1 resided in the Independent Living area of the facility. They were ambulatory with an assisted walking device and paid for a private caregiver. Facility has been in contact with the Marin Coroner regarding R1. Incident Report #2: CCL received an incident report from the facility on 1/27/2023. The incident occurred on 1/27/2023. The report stated that Resident 2 (R2) was observed by staff trying to get out of bed. R2 was observed to have a skin tear on their leg. Staff applied first aid and monitored R2 appropriately. Facility made appropriate notifications per regulation. LPA, Executive Director, and Charge Nurse discussed R2. R2 has a history of skin tears and was observed to have a change of condition and increased care needs. As of today, 3/9/2023, R2 has transitioned out of the facility’s Assisted Living and now resides in the facility’s Memory Care. Incident Report #3/SOC-341: CCL received an incident report from the facility on 2/14/2023. The incident occurred on 2/14/2023. Continued on LIC809C Continued from LIC809 The report stated that the Facility was informed by Resident 3 (R3’s) Responsible Party of potential financial abuse occurring between R3 and their private caregiver. Facility made appropriate notifications per regulation. LPA, Executive Director, and Charge Nurse discussed R3. Facility has been in contact with R3’s Responsible Party and Law Enforcement. Until the investigation is complete, the private caregiver has been suspended from being at the facility. Per conversation with the Executive Director and Charge Nurse, R3’s responsible party reviewed R3’s finances and made appropriate changes. The police investigation regarding the incident is still pending. No Deficiencies Cited during visit.the state’s words, verbatim · CDSS document, Mar 9, 2023

Allegation investigated: Neglect/Lack of supervision resulting in resident sustaining unexplained injuries

At approximately 10:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Executive Director, Shannon Brown, and Charge Nurse, Melanie Fenn. During the course of the investigation, LPA Felias reviewed and requested documents, made observations at the facility, and conducted interviews. There is an allegation of Neglect/Lack of supervision resulting in resident sustaining unexplained injuries. Based on information provided to LPA, the unexplained injury was described as a “gash” on Resident 1’s (R1) scalp and bruising on their cheek. Review of Facility documents during the alleged timeframe of injury did not show any written documentation of a gash being observed on R1’s scalp. Review of R1’s Physician Report dated 10/04/2018, indicated that R1 does not have dementia and can communicate their needs. Based resident interviews conducted, LPA received inconsistent information regarding how facility staff treat residents. Continued LIC9099C Unsubstantiated Continued from LIC9099 However, interview conducted with R1 stated that the staff are wonderful and help them with their care needs. R1 stated that they do not know where the bruises came from and stated they just happen. Staff interviews conducted indicated that there have been no observations made where staff treated residents roughly. Based on Record Review, observations made, and inconsistent information provided during interviews conducted, the LPA is unable to determine if the facility neglected or had a lack of supervision in resident's care resulting in unexplained injuries. Therefore, this allegation is Unsubstantiated. A finding that the complaint is Unsubstantiated means that 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. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 7, 2023 · control 21-AS-20221007124556

Allegation investigated: Staff do not provide enough liquids to resident in care Staff did not report resident's incident to resident's authorized representative

At approximately 11:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for the Complaint Investigation regarding the above allegations and met with Executive Director, Shannon Brown, and Charge Nurse, Melanie Fenn. During the course of the investigation, LPA Felias reviewed and requested documents, made observations at the facility, and conducted interviews. There is an allegation that Staff do not provide enough liquids to resident in care. Interview conducted with Resident 1 (R1) stated that facility offers snacks and drinks to them. Other resident interviews conducted stated that staff offer drinks frequently. During visit conducted 2/7/2023, LPA observed a sign showing that staff offer snacks and drinks every day at 3:30PM. Based on observations made and interviews conducted, the LPA is unable to determine if staff do not provide enough liquids to resident in care. Therefore, this allegation is Unsubstantiated. Continued on LIC9099C Unsubstantiated Continued from LIC9099 There is an allegation that staff did not report resident’s incident to resident’s authorized representative. Based on interviews conducted, LPA received inconsistent information. Staff interview conducted indicated that the incident involving R1 occurred on the same day that R1’s authorized representative visited the facility. The staff member, authorized representative, and a Pine Parks Representative discussed the incident involving R1. LPA was unable to conduct an interview with the Pine Parks Representative. Multiple attempts were made to obtain their contact information were unsuccessful. Based on inconsistent information provided during interviews conducted, the LPA is unable to determine if staff did not report resident’s incident to resident’s authorized representative. Therefore, this allegation is Unsubstantiated. A finding that the complaint is Unsubstantiated means that 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. No Deficiencies Cited during visit. Exit interview conducted. Copy of report, and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 7, 2023 · control 21-AS-20221025151918

Type of visit: Case Management - Other

At approximately 12:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit and met with Executive Director, Shannon Brown, and Charge Nurse, Melanie Fenn. The purpose of the visit is to follow up on a plan of correction cited on 12/29/2022 and review expectations for annual visits. LPA Felias, Executive Director, and Charge Nurse discussed the following: Incident Reports/Death Reports Status Solutions Audit for Call Light System Full Annual Expectations Updating Staff and Resident Files as needed Staff Training No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 7, 2023

Allegation investigated: Facility does not have adequate staff to meet the needs of residents Staff does not respond to resident's emergency call button in a timely manner

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Aldersly for the purpose of delivering complaint findings. LPA met with, Executive Director, Shannon Brown, and was granted access into the facility. Also participating during the delivery of findings were, Melanie Fenn. During the course of the investigation, LPA Felias reviewed and requested documents, made observations at the facility, and conducted interviews. There is an allegation that Staff does not respond to resident’s emergency call button in a timely manner and Facility does not have adequate staff to meet the needs of residents. A review of facility’s call button logs showed that multiple resident pendants had wait times of an hour or more before being cleared. It was also observed that the call buttons would reset and continue to alarm until they were cleared by staff. Interviews conducted stated that residents have waited for staff assistance for as long as 20 to 40 minutes or would have no staff respond at all. It was stated that some residents no longer use their pendants because they do not feel confident that someone will help them. (Report continued on LIC 9099C) Substantiated Staff interviews conducted stated that there have been issues with the pendant devices such as call buttons alarming when residents have not called for assistance and alarming for residents who were out of the facility, or no longer residing at the facility. Interviews revealed that sometimes staff members would forget to clear the call button after assisting a resident resulting in the button continuing its alarm until it was properly cleared. Interviews conducted indicated that the facility was aware of the devices having issues but could not determine its cause. LPA was informed that the call light system would be undergoing a system audit to address the issues observed with the call light system and defective pendants. Based on documents reviewed, observations made, and interviews conducted, the allegations that Staff do not respond to resident’s emergency call button in a timely manner and Facility does not have adequate staff to meet the needs of residents have been Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Dec 29, 2022 · control 21-AS-20220907101331

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 30, 2022

87411(a) Personnel Requirements – General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement has not been met as evidenced by: Based on records reviewed and interviews conducted, facility staff were unable to respond to resident care needs and call buttons in a timely manner. Records reviewed indicated that multiple call buttons had response times of an hour or longer. Interviews stated that there was an issue with facility pendants not working properly. This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 29, 2022

Plan of correction: Licensee to submit a self-certification statement that a plan of action will be written regarding facility staffing and call light system by POC due date of 12/30/2022. Plan of action to detail how facility will ensure there is sufficient staff available to respond to resident care needs in a timely manner and to include a timeline of when call light system is expected to be audited. Facility to notify CCL of any updates involving system audit progress or delays. Plan to be submitted to CCL by POC date of 01/09/2023.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Aldersly for the purpose of conducting a Case Management-Deficiencies inspection. LPA was greeted at the door by, Executive Director, Shannon Brown, and was granted access into the facility. During the course of the Complaint Investigation dated for September 7, 2022 LPA Felias reviewed and requested documents. LPA learned that Resident 1 (R1) had a fall that resulted in a fracture. This incident was not reported to Community Care Licensing (CCL) and was not documented on an LIC 624/Unusual Incident Report Form (See LIC-809D). In addition, LPA observed that facility has not submitted any incident reports to CCL for the month of November 2022 to December 2022. LPA and Administrator discussed the importance of reporting incidents in a timely manner. ***An immediate civil penalty in the amount of $250.00 has been issued for a repeat violation of the California Code of Regulations (CCRs) Section 87211. The civil penalty will continue to accrue $100 per day per violation until the violation is corrected. Exit interview conducted. Copy of report, LIC-809D, LIC-421FC, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.the state’s words, verbatim · CDSS document, Dec 29, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211 · Plan of correction due date: Dec 30, 2022

87211 Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on Record Review, the Licensee did not comply with the section cited above, and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 29, 2022

Plan of correction: Licensee to provide training to all Staff and review the Regulation: 87211 Reporting Requirements, how to properly fill out the LIC 624 form, and provide information on where to submit them. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 1/09/2023.

Type of visit: Required - 1 Year

At approximately 1:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required - 1 Year Visit, and met with Administrator, Momo Duoa, and Executive Director, Shannon Brown. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival at the facility, LPA had their temperature checked and logged. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a cleaning and disinfecting schedule that occurs at least once per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for Residents. LPA and Administrator discussed the following: Vaccinations, activities, staffing, incident reports. Facility has a plan in place if a staffing shortage were to occur. Facility submitted their Mitigation/Infection Control Plan to Community Care Licensing (CCL). Fire extinguishers were last serviced January 2022. Facility had fire inspections conducted on September 22, 2021, and November 1, 2022 where smoke and carbon monoxide detectors were tested and operational. The last facility disaster drill was conducted October 20, 2022. Continued on LIC-809C Continued from LIC-809 LPA requested the following documents to update facility file: Administrative Organization (LIC 309) Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Liability Insurance Surety Bond Documents to be submitted to CCL by due date of Tuesday, November 29, 2022. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 8, 2022

Type of visit: Case Management - Other

At approximately 3:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other visit, and met with Administrator, Momo Duoa. The purpose of the visit is to discuss the facility's dementia care program. Documents supporting the program will be submitted to Community Care Licensing (CCL). No deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 1, 2022

Allegation investigated: Resident fell resulting in injuries to the face Lack of cleanliness of the facility Lack of staffing

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Aldersly for the purpose of delivering complaint findings. LPA was greeted at the door by Executive Director, Shannon Brown, and was granted access into the facility. During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses. LPA conducted tours of the facility on June 22, 2022, July 7, 2022, September 12, 2022 and September 27, 2022. Complaint alleges that Resident fell resulting in injuries to the face. Based on interviews, LPA could not determine the date or time of the unwitnessed fall due to insufficient information regarding the fall itself. In addition, LPA reviewed the fall procedures for the facility and found that the facility followed their own fall procedure plan as it relates to unwitnessed fall. (Report continued on LIC 9099C) Unsubstantiated Complaint alleges lack of cleanliness of the facility. LPA toured the facility on June 22, 2022, July 7, 2022, September 12, 2022 and September 27, 2022 and found that on all those tours of the facility, facility was found to be clean and at a comfortable temperature. During the initial tour on June 22, 2022, LPA did observe a stain on R1’s carpet that was in the process of being cleaned. However, during subsequent tours conducted on said dates, LPA did not observe the same stain on R1’s floor during subsequent tours of the facility as the carpet was observed to be cleaned. Based on interviews with witnesses, LPA learned that there are no concerns with the physical plant itself. Complaint alleges lack of staffing. LPA toured the facility on June 22, 2022, July 7, 2022, September 12, 2022 and September 27, 2022 and found that on all those tours of the facility, the facility was observed to be staffed. During interviews with staff, residents and witnesses, LPA received inconsistent statements regarding the staffing allegation. LPA reviewed the call bell log and could not find any evidence to suggest that the facility was understaffed. In addition, during a review of the facility records, LPA could not prove or disprove that the facility lacked staffing. A finding that the complaint allegations of, Resident fell resulting in injuries to the face, lack of cleanliness of the facility and lack of staffing are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and emailed to the Executive Director due to printing issues.the state’s words, verbatim · CDSS document, Oct 3, 2022 · control 21-AS-20220620085447

Type of visit: Case Management - Other

At approximately 2:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit, and met with Executive Director, Shannon Brown, Resident Care Director, Momo Duoa, and Nurse, Melanie Fenn. The purpose of the visit was to follow up on Change of Administrator paperwork needed for Executive Director, Shannon Brown. At this time, Momo Duoa, Resident Care Director, is the current Administrator who oversees the facility. Shannon Brown will be considered Back-Up Administrator in the event Momo Duoa, is unavailable. LPA is requesting the following documents: LIC 308 (Designation of Facility Responsibility) Active and Current Administrator Certificate First Aid Certificate Administrator Resume LIC 501 (Personnel Record) LIC 503 (Health Screening Report - personnel) Proof of TB test LIC 9182 (Criminal Record Exemption Transfer Request) LIC 508 (Criminal Record Statement) Copy of Driver's License or Passport that is not expired Facility to submit Administrator Paperwork documents to Community Care Licensing (CCL) by Friday, 9/23/22. Facility to submit Active Certificate when available. Continued on LIC-809C Continued from LIC-809 LPA conducted a walk-though of facility with Nurse, Melanie Fenn. No Deficiencies cited during visit. Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 13, 2022

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Aldersly for the purpose of conducting a Case Management- Deficiencies inspection. LPA was greeted at the door by Executive Director, Shannon Brown, and was granted access into the facility. During the subsequent complaint investigation inspection dated for July 7, 2022, LPA toured the facility at 09:15 AM with the Executive Director and observed Resident #1's (R1's) room being clean, but the closet where the resident stores clothing had a trash bag tied (See LIC 812-Picture taken) around preventing the resident from accessing clothes which presents a Personal Rights issue. Executive Director removed the trash bag. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 7, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 7, 2022

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: During a tour of the facility, LPA observed a trash bag on R1's closet that prevents R1 from obtaining clothing to wear. This presents an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2022

Plan of correction: *Executive Director removed the trash bag from the closet door. Licensee shall train staff on Personal Rights and provide proof of training along with a sign-in sheet by July 12, 2022.

Allegation investigated: Resident's fell multiple times while in care Resident's sustained minor injuries while in care Unqualified staff providing care to resident's Staff are not providing resident's with adequate laundry service Staff are not meeting resident's hygiene needs

Licensing Program Analyst (LPA), Farhaan Sarangi conducted a complaint investigation for the purpose of delivering complaint findings. LPA met with Staff Member, Momo Dua and was granted access into the facility. During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses. LPA conducted a tour of the facility on February 24, 2022, March 02, 2022 and April 5, 2022. Complaint alleges that Resident's fall multiple times while in care and sustain minor injuries while in care. Based on interviews, LPA learned that R1 sustained a fall and pressed the pendent multiple times. However, dates and times could not be recalled. LPA performed a review of the Pendent Call Log for 60 days and found that on February 12, 2022, R1 did fall and waited approximately 11 minutes to be retrieved from the floor. Report continued on LIC 9099-C Unsubstantiated LPA learned that the facility tries to retrieve residents from the floor in a timely manner and as quickly as possible. During these falls, LPA learned that minor injuries were disclosed to appropriate parties but was not reported to Community Care Licensing Division (See LIC 809). Complaint alleges that Unqualified staff provides care to residents. Based on observations of facility training records LPA learned that the facility does onboard training of staff members. LPA confirmed via a review of the LIC 500 and a review of current training records that a newly hired Medication Technician that was hired in late 2021 and is currently going through the on boarding training hours at the facility. During the tours and observations of the facility dated on February 24, 2022, March 02, 2022 and April 5, 2022, LPA observed sufficient staff members at the facility. LPA also observed the facility to be clean and exits free from obstruction. During the tour on April 5, 2022, LPA tested the call light in R1's room, and found that staff responded within an appropriate time frame. Complaint alleges that staff are not providing resident's with adequate laundry service and are not meeting resident’s hygiene needs. LPA interviewed identified staff members, various outside parties, Resident #1 (R1) and Resident #2 (R2). Based on the interviews that were conducted and the information received, there was inconsistent information and no concerns with laundry or resident’s hygienic needs. A finding that the complaint allegations of, Resident's fall multiple times while in care, Resident's sustained minor injuries while in care, Unqualified staff providing care to resident's, staff are not providing resident's with adequate laundry service and are not meeting resident’s hygiene needs are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Staff Member, Momo Dua.the state’s words, verbatim · CDSS document, Apr 5, 2022 · control 21-AS-20220104105304

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Farhaan Sarangi conducted a Case Management-Deficiencies inspection. LPA met with Staff Member, Momo Dua and was granted access into the facility. During the course of the complaint investigation dated for January 4, 2022, LPA learned that R1 did sustain a fall that was unreported to licensing. In addition, incidents were not documented on an LIC 624/Unusual Incident Reports. (See LIC 809D). The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 5, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211 · Plan of correction due date: Apr 6, 2022

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. (C) The use of an Automated External Defibrillator. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met evidenced by: Based on interviews with facility staff, and research of incident reports submitted to CCL, facility did not properly report an incident to the CCL as required by Title 22 regulation. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 5, 2022

Plan of correction: Administrator to arrange for in-service training for staff regarding Reporting Requirements. Report and plan for training to be submitted to Santa Rosa CCL office by POC date of April 6, 2022. Proof of training along with a sign-in sheet shall be furnished to Santa Rosa CCL office by April 13, 2022.

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Aldersly unannounced for the purpose of reviewing the physical plant for a capacity increase. LPA was greeted by Administrator, Gilbert Carrasco, and was granted access into the facility. LPA toured the facility, including the area involved in the capacity increase. LPA observed rooms that appear to be able to accommodate 15 residents. LPA observed 5 private bedrooms and 5 shared bedrooms. The 5 shared bedrooms will have 2 residents per room. Rooms are furnished per regulation. LPA has received fire safety inspection approving the increase. LPA observed two fire extinguishers that were dated for January 2022. Exits were free from obstruction in rooms. Licensee is requesting capacity increase from 122 to 137. New construction was completed on December 2021. During the Case Management inspection, LPA obtained a new facility sketch designating new facility rooms. No deficiencies were observed or cited in the areas toured by LPA. Exit interview was conducted and a copy of this report was signed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Feb 10, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Aldersly for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Administrator, Preet Kaur. LPA was granted access into the facility. The facility is composed of multiple buildings for CCRC with independent living and assisted living setting licensed by Community Care Licensing on all floors. The assisted living setting is on a building in the right side of the facility. The facility also has a skilled nursing setting that is not licensed by Community Care Licensing. LPA toured the facility at 11:00 AM with Administrator, Preet Kaur; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were free from obstructions at the time of the visit. Fire Extinguisher was found to be last charged on 01/2021 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors, carbon monoxide, and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 07/29/2021 . There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 115.8 degrees F and 120.0 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in bathrooms while touring the facility. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPA toured the kitchen area on and learned that there are provisions made for individuals/residents with special dietary needs. Facility has posted in assisted living kitchen resident’s names and their needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked room. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. Facility understands that all beds should be outfitted with mattress pads as per Title 22 Regulations # 87307. (Report continued on LIC 809C) LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE in the office and attic. Facility is in the process of being N95 Fit tested. No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Preet Kaur.the state’s words, verbatim · CDSS document, Sep 9, 2021

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff installed inappropriate alarm on resident's door.

Licensing Program Analyst (LPA), Farhaan Sarangi conducted a complaint investigation for the purpose of delivering complaint findings. LPA met with Administrator, Preet Kaur and was granted access into the facility. LPA Sarangi initiated an investigation beginning on April 14, 2021 at approximately 09:10 AM. During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses. LPA conducted a virtual tour of the facility on April 14, 2021 at approximately 12:30 PM to inspect the alarm outside of resident R1’s door and to observe a camera in the hallway. Report continued on LIC 9099-C Unsubstantiated Complaint alleges that Staff installed inappropriate alarm on resident's door. Based on observation and interviews during a virtual tour conducted on April 14, 2021, LPA verified the volume of the door alarm outside of R1s room. During interviews with witnesses learned that it was disclosed that the alarm was a volume that might cause the resident not to come out of the room. Facility was made aware of this and rectified the issue right away by turning down the alarm to a level that staff members can hear without causing stress to residents. In addition, LPA verified that a camera in a common hallway which is not directed towards or is inside the resident’s room and does not infringe on the Personal Rights of the residents in care. LPA observed that the camera that was in the hallway pointed at the wall across from where the camera was situated and where no resident room was located. Camera was also inaccessible on a mobile device reflecting no audio and was only accessible on a computer inside a room close to the Administrators office. A finding that the complaint allegation Staff installing inappropriate alarm on resident's door will be unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report continued on LIC 9099A This agency has investigated the allegation of Resident’s responsible party not being notified of resident’s room modifications. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No citations issued this visit.the state’s words, verbatim · CDSS document, Aug 10, 2021 · control 21-AS-20210413081143