Appearance Quality Home

Type of visit: Required - 1 Year

On 09/11/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Caregiver, Blanca Cabrera, and introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in care. The facility has 6 bedrooms, 3 bathrooms, kitchen, dining area, living room, office, attached garage, and backyard. LPA completed a walk through of facility and review of records. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 108.3 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguishers and emergency kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA observed the emergency disaster plan not reviewed since April 2022. Deficiency issued. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated locked storage space for resident/staff files and medication. Food Service: Non-perishable and perishable food supply is not sufficient for number of residents in care. LPA observed lots of expired perishable and nonperishable food. Deficiency issued. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, a side gate with a locked door knob on the right side of the house that leads into the backyard, a shed and industrial container used as storage. Deficiency issued for locked gate due to not notifying the licensing agency. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Not all staff members working in the facility have criminal record clearance through the department. Deficiency issued with civil penalty. Record Review: LPA reviewed 4 resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed an incomplete resident file for resident 1 (R1). Deficiency issued. LPA also reviewed administrator's and 4 staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed incomplete personnel records for (S1) (S2) and (S3). Deficiency issued. LPA also observed missing trainings for first aid/cpr and medication for staff. Deficiency issued. LPA observed that the facility did not have an Infection Control Plan. Deficiency issued. Eight deficiencies and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC421BG and appeal rights were discussed and copies were provided to the Administrator Rachel Riley who later arrived.the state’s words, verbatim · CDSS document, Sep 11, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rayshaun Nickolas conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Nickolas arrived and met with Administrator, Rachel Riley. The administrator confirmed that there are currently no cases/exposures of COVID-19 within the facility. During the inspection, LPA Nickolas conducted a tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA Nickolas observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division (CCLD) guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. LPA observed locks on the pantry and refrigerators, restricting the clients access to food without an approved waiver on file. Based on observations made during today’s inspection, one deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were given to the Administrator.the state’s words, verbatim · CDSS document, Jun 23, 2022

Allegation investigated: Facility staff did not seek timely medical attention for resident Facility staff did not report injuries to Department in a timely manner

Licensing Program Analyst's (LPA's) Stephanie Williams and Rayshaun Nickolas made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegations. LPA's Williams and Nickolas identified themselves to Caregiver, Blanca Gonzalez, who was also informed of the purpose of the visit. LPA Williams spoke with the Administrator, Rachel Riley, over the phone. The investigation consisted of direct observations, records review, and interviews with staff and residents. In regard to allegation #1, Department staff reviewed R1’s medical records. The medical records revealed that on 2/19/2018, R1 was seen in the emergency room for a laceration to the head as a result from an accident at the facility. The medical records further indicate that facility staff did not retrieve timely medical attention for R1 on the night that the injury was sustained on 2/18/2018. Department staff interviewed S1 regarding S1’s medical training. S1 stated that a patient with obvious head trauma would need to undergo a CT scan. Department staff then asked S1 why R1 was not provided medical care after obvious head trauma, to which S1 responded that, R1 is very independent. Furthermore, facility staff could not produce documentation showing that R1 received timely medical attention after sustaining head trauma on 2/18/2018. Substantiated In regard to allegation #2, Department staff interviewed S1, who stated that the facility has had several residents who have experienced a fall while residing in the facility. S1 admitted that the falls, which resulted in injuries, were not reported to the Department because the residents were on hospice. LPA Williams reviewed the Department’s records which showed that the facility sent several incident reports to the Department from 2017- 2019; however, the last incident report which was recorded by the Department from the facility was on 4/10/2019. Furthermore, LPA Williams retrieved an incident report dated 3/7/2021 while visiting the facility, which noted that R1 had been admitted to the hospital for altered mental capacity and lethargy. LPA Williams did not observe the incident report that logged in the Department’s records. Department staff interviewed S1 regarding the incident report dated 3/7/2021 and questioned why the incident report did not include the several injuries that were noted in R1’s medical records. S1 stated that it may have been an oversight on S1’s part. In addition to the incident report dated 3/7/2021 not being complete, it was also not recorded within the Department’s time frame for reporting requirements. Based on the information and interviews gathered the above allegations is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Please see LIC 9099D for deficiencies cited. An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to Gonzalez at the conclusion of the visit. (R3) who denied being physically abused by facility staff members. An attempt to interview Resident #4 (R4) was made by Department staff; however, R4 was unable to make a statement. Department staff was unable to interview R2 as a result of R2’s passing prior to the investigation. Furthermore, another witness, Witness #2 (W2), stated that they observed injuries on R2 during a visit to the facility. W2 stated they questioned S1 and S2 of R2’s injuries, to which S1 stated that R2 experienced a fall. S1 was shown the photos of several residents with various injuries. S1 initially stated that Resident #2 (R2) had sustained the injuries as a result from a recent vaccination. However, S1 then changed their story and stated that R2 experienced a fall while at the facility. S2 and S3 both denied that R2 experienced a fall while residing in the facility. At the time of closure of this investigation, there is insufficient evidence to prove or disprove that the injuries to the residents were a result of physical abuse caused by staff members. Therefore, the allegation is unsubstantiated. Based on evidence obtained during the investigation, LPA has determined that the above allegation 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. An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to Gonzalez at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 6, 2022 · control 18-AS-20210921132836

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Apr 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: (16) To receive or reject medical care or other services. This requirement has not been met as evidenced by: Based on interviews, the Licensee did not seek timely medical attention for R1. This is a immediate health and safety risk to resident's in care.the state’s words, verbatim · CDSS document, Apr 6, 2022

Plan of correction: The Licensee shall conduct training on Regulation 87468.1 for all staff and send proof to the Department by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Apr 13, 2022

87211 - Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1)... (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 evidenced by: Based on interviews and observations, the Licensee did not ensure that serious injuries were reported to the Department in a timely manner. This is a potential health and safety risk to resident's in care.the state’s words, verbatim · CDSS document, Apr 6, 2022

Plan of correction: The Licensee shall conduct training on Regulation 87211(a)(1)(B) for all staff and send proof to the Department by POC date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst's (LPA's) Stephanie Williams and Rayshaun Nickolas made an unannounced visit to the facility in order to conduct a case management visit. LPA's Williams and Nickolas identified themselves to Caregiver, Blanca Gonzalez, who was also informed of the purpose of the visit. LPA Williams spoke with the Administrator, Rachel Riley, over the phone. On 1/12/22, a Department Investigator interviewed Staff #1 (S1) regarding allegations made on Complaint Control #18-AS-20210921132836. According to the Investigation Report, S1 indicated that on at least occasion, they threatened to "punch" Resident #1 (R1). Deficiencies are being cited for violations of resident's Personal Rights. An exit interview was conducted where this report was discussed and a copy was provided to Gonzalez at the end of the visit.the state’s words, verbatim · CDSS document, Apr 6, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 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, ... This requirement has not been met as evidenced by: Based on interviews, the Licensee did not ensure the personal rights of R1. This is an immediate personal rights risk to resident's in care.the state’s words, verbatim · CDSS document, Apr 6, 2022

Plan of correction: The Licensee shall conduct training on Regulation 87468.1 for all staff and send proof to the Department by POC date.

Allegation investigated: Staff member physically abused resident while in care. Staff threatened resident while in care. Staff moved resident without consent/illegal eviction

Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegations. LPA met with Caregiver, Blanca Gonzalez and discussed the purpose of the visit. The Administrator, Rachel Riley, was unavailable at the time of visit; however, LPA spoke with Riley over the phone. The investigation consisted of records review and interviews with staff and residents. In regards to allegation #1, LPA interviewed Resident #1 (R1) who stated that Staff #1 (S1) slapped R1 in the face and pulled R1's hair; however, R1 could not recall the time of the incident or if there was any eyewitnesses. R1 could not recall further details. LPA interviewed S1, Staff #2 (S2), and Staff #3 (S3) who all denied physically abusing the residents nor did they witness other staff members physically abuse residents. LPA interviewed Resident #2 (R2) and Resident #3 (R3) who denied being physically abused nor did they witness any physical abuse by staff members. Both R2 and R3 stated that facility staff have treated them well. LPA interviewed Witness #1 (W1) who stated that R1 had reported that they were being physically abused. Unsubstantiated W1 stated that R1 was checked for any marks/injuries/bruising but did not find any. In regards to allegation #2, LPA interviewed R1 who stated that facility staff would threaten to send R1 to the "mental hospital" if R1 reported the alleged physical abuse occurring to R1. LPA interviewed S1, S2, and S3, who all stated that they did not threaten R1. S1, S2, and S3 stated that there was no physical abuse to report. LPA interviewed R2 and R3 who both stated that they have not felt threatened while residing at the facility. In regards to allegation #3, LPA interviewed S2 who stated that R1 has requested to move out of the facility on numerous occasions and consented to being placed at R1's current home. LPA interviewed R1, who stated that they are unaware of who and how they were placed into another home. R1 stated that R1 is unaware if an eviction notice was provided to them. LPA asked if R1 consented to being placed into another home, to which R1 could not provide a consistent response. LPA interviewed S1 who confirmed S2's interview statement that R1 requested to be moved into another facility and consented to being moved. Based on evidence obtained during the investigation, LPA has determined that the above allegations are 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. An exit interview was conducted where this report was discussed and a copy was provided to the Administrator via email.the state’s words, verbatim · CDSS document, Sep 13, 2021 · control 18-AS-20210907121129

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Javina George conducted an unannounced health and safety check. LPA met with Administrator Rachel. Upon arrival LPA observed that the gate is still broken, the facility is using a lock that is typically used to secure a bike (rubber/plastic with a combination). Per previous discussion with Administrator the gate was to be fixed by 6/30/21. Administrator called the repair man during LPA's visit whom stated that he ordered the part and the fence should be fixed next week. LPA toured the physical plant and observed the facility to still be under construction. Administrator submitted the plans for construction to LPA during the visit, that were requested May 27, 2021 during LPA's last visit. The projected completion date is August 2021. LPA observed that there is still a lock on the refrigerator as well as the pantry. The facility has more than the minimum requirement of a 2 day supply of non perishable food items and a 7 day supply of perishable food items. LPA observed and greeted all resident's except one due to them being asleep during LPA's visit. The resident's were groomed, and appropriately dressed. At 10:57am LPA observed the facility to be over capacity. There to be an extra individual Resident # 7 (R7) asleep inside of bedroom number two, whom was identified as a resident and was placed by the County, per Administrator Rachel. Note that R7 is associated to the facility. LPA discussed the need to have someone relocated, as it is an immediate health and safety risk to the resident's in care, as the facility's fire clearance only granted approval for 6 non ambulatory resident's. Per Administrator there is supposed to be another resident #4 (R4) moving out by the end of this week. The move out date was confirmed to be tomorrow 7/16/21 afternoon. Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, and appeal rights were provided to Administrator Rachel Riley.the state’s words, verbatim · CDSS document, Jul 15, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Jul 16, 2021

87204 Limitation-Capacity and Ambulatory status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... This requirement is not met by: Based on observation, interview, and record review the licensee did not stay within capacity on 1 of 1 times.the state’s words, verbatim · CDSS document, Jul 15, 2021

Plan of correction: The licensee will relocate R4 by 3pm on the due date indicated. Licensee will submit proof to the department.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Caregiver Roseline Osakpolor, and explained the purpose of the visit. Administrator Rachel joined shortly after. At the time of visit there were 2 staff and 6 residents present. The facility currently has zero positive or suspected Covid-19 cases. During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer), as well as Personal Protective Equipment (PPE) supplies. The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Rachel Riley.the state’s words, verbatim · CDSS document, Jul 15, 2021