Arbor House

Allegation investigated: - Facility staff are drinking alcohol at the facility

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings into the allegations received. LPA met with administrator Victoria Alejandro and explained the purpose of today's visit. During the course of the investigation LPA conducted interviews and made observations. Interviews conducted revealed that the above allegation did take place. This discovery was made by a facility manager who made a late night visit to the facility around 10:45pm and discovered the staff persons S2, S3, and S4 in the garage of the facility playing loud music and observing a bottle of alcohol and cups present. These staff persons and other staff persons employed at this time were terminated, or resigned, for not reporting these items to the administrator. This allegation is substantiated. Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with the administrator Victoria Alejandro. Substantiatedthe state’s words, verbatim · CDSS document, Sep 13, 2023 · control 14-AS-20221209144007

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 14, 2023

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: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This regulation has not been met as evidenced by: According to interviews S1 discovered during a night time unannounced visit to the facility 3 staff persons, S2, S3, and S4 in the garage of the facility with alcohol, cups, and music playing.the state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: Facility terminated S2, S3, and S4 shorty after the incident occurred. In-service training to be conducted regarding staff conduct policies and reporting of incidents among staff. A sign in sheet and materials are to be submitted to the Department to show the trainings took place.

Allegation investigated: Administrator is not present on the premises a sufficient number of hours to manage the facility

On 8/28/2023, Licensing Program Analyst (LPA) Grace Donato Grace Donato conducted an unannounced 10-day complaint inspection. LPA Donato met with Administrator, Victoria Alejandro. LPA Donato explained the purpose of the visit. Regarding the allegation that Administrator (S1) is not present on the premises with a sufficient number of hours to manage the facility. Reporting party (RP) stated that S1 is not present to provide adequate attention to the management and administration of the facility. LPA conducted interviews and reviewed documents regarding S1 and the allegations. Two out of two staff members interviewed stated that administrator works at facility and sometimes covers other caregivers who would call out. Interviews confirm that S1 comes to the facility to help manage and do admin work. Based on documents provided, while S1 may not be on the premises there is a designated responsible person who oversees the facility. This allegation is unsubstantiated. Unsubstantiated Based on these observations, interviews & record reviews, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report discussed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Aug 28, 2023 · control 14-AS-20230821141221

Type of visit: Case Management - Incident

On 7/6/2023, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning an incident report received. LPA met with Lead Staff (LS) Veronica Rozario. LPA explained the purpose of today's visit. On 7/5/2023, facility submitted an incident report concerning resident a resident (R1) was given a wrong medication. During today's visit, LPA observed medications to be locked and inaccessible to residents. Residents were at the living room watching a movie. In regard to the incident, LS stated that on the day the incident occurred, the staff (S1) was on NOC shift. S1 was giving out medication in the morning and accidentally gave the wrong set of medication to R1. R1 already ingested the medication so S1 called administrator to report and then poison control was called for advice. S1 is currently not allowed to give out medications. S1 has medication training. Facility staff members will have training again in regard to resident medications. Deficiency is cited today as the facility did not ensure that correct medications is given to residents. Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with lead staff, Veronica Rozario. A copy of this report and the Appeal Rights are provided.the state’s words, verbatim · CDSS document, Jul 6, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Jul 7, 2023

87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met as evidenced by caregiver did not ensure that the correct medication is given to the resident.the state’s words, verbatim · CDSS document, Jul 6, 2023

Plan of correction: The licensee and/or administrator will review the regulation, develop a plan to ensure this incident does not happen again. The plan needs to include on how to make sure that correct medication is given to residents. In addition, the plan needs to include staff training. The administrator/licensee will provide a copy of such plan and a sign-in record of staff training to CCL by 7/7/2023.

Type of visit: Collateral

On this day Licensing Program Analyst (LPA) Jaime Vado conducted a collateral visit at this facility in order to deliver findings for another facility, Cypress Home #415601119 due to Cypress being in a fire an inaccessible at this time. LPA Vado discussed with the administrator of Cypress Virctoria Alejandro the allegation findings via telephone. LPA met with facility manager Veroncia Rozario and explained the purpose of today's visit. LPA Vado discussed and delivered findings to Veroniza Rozario on this day. No citation issued. Report discussed with Veronica.the state’s words, verbatim · CDSS document, Jun 30, 2023

Type of visit: Case Management - Other

On March 13, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit. LPA met with Administrator, Victoria Alejandro and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude an employee of the facility. The letter was given to the Administrator. This report is reviewed and discussed with the Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Mar 13, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator Victoria Alejandro arrived later. The inspection is focused on the Infection Control procedures and practices of this facility. LPA was screened for Covid-19 by staff including having temperature checked and filling out a questionnaire with standard Covid-19 screening questions. LPA initiated a walk-through of the facility around 1:30pm and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected two times per day. Facility maintains documentation of staff and resident daily temperatures. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) but have not been N95 fit tested. Administrator and LPA discussed visitation and activities. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced May 2021. Facility has combination hardwired smoke and carbon monoxide detectors that were tested and operational during inspection. Continued on LIC809C Continued from LIC809 Administrator and LPA discussed their Emergency Disaster Plan, Mitigation Plan and Infection Control Plan. Licensee/Administrator to submit updates of the following documents by 12/16/2022: LIC 308 Designated Administrator (if applicable) LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (review and update) Copy of Liability Insurance No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Nov 18, 2022

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: Facility not following program designed

On October 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Caregiver, Arthur Grace and explained the purpose of the visit. Regarding the allegation that the facility is not following program design, according to the reporting party, there are 3 residents that are required to have a 1 on 1 caregiver for all 3 shifts according to the program design. During the investigation, LPA reviewed the facility program design and interviewed staff. Based on the program design that the facility submitted and got approved, the facility indicated that 1:1 staffing will be provided during most waking hours and two staff providing awake supervision and care during sleeping hours. On 9/8/2022 and 10/20/2022, LPA Charitra conducted complaint visits to the facility in the morning and observed 2 staff members present both times for the 3 residents. In addition, interviewed staff indicated there are normally 2 staff members present during the AM shift, 2 staff present during the PM shift and 2 staff during NOC shift. Although, the Administrator is constantly hiring staff members for the facility to meet resident's needs and progrm designed, the Licensee failed to follow the program design in order to meet the resident’s care and supervision. Based on the observations and interviews conducted, it was determined facility is not following program designed. The preponderance of evidence standard has been met, therefore the above allegation is determined to be Substantiated. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Caregiver, Arthur Grace, and a copy is provided with appeals rights. Caregiver refused to sign. Substantiated Regarding the allegation that unqualified staff are providing medications to residents without proper training, according to the reporting party, during interview with reporting party, it was indicated that unqualified staff are providing residents with medication without DSP (direct support professional) training. During the complaint investigation, LPA Charitra interviewed staff members, reviewed staff training records, and reviewed resident medication records and it was indicated that all staff who provide resident's medications are observed to have their DSP training. Based on the interviews conducted, records reviewed, and information collected, the allegation that unqualified staff are providing medications to residents without proper training is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed with Caregiver, Arthur Grace and a copy is provided with appeals rights. Caregiver refused to sign.nthe state’s words, verbatim · CDSS document, Oct 20, 2022 · control 14-AS-20220609161732

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Oct 27, 2022

Plan of operation: Each facility shall have and maintain a current, written definitive plan of operation... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval… The plan and related materials shall contain the following…Statement of purposes and program goals…Administrative organization, Staffing plan, qualifications, and duties. Plan for training staff, as required by Section 87411(c). Violation of this regulation is evidenced by: Based on observations, LPA visited the facility on 9/8/2022 and 10/20/2022 and observed 2 staff members present during the AM shift. In addition, interviewed staff indicated there are normally 2 staff members present during the AM shift.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: Facility Administrator/Licensee is constantly working on hiring staff members to meet program designed. Administrator will submit LPA a written plan on how facility can meet program designed

Type of visit: POC

On June 30, 2022, Licensing Program Analysts (LPA) Komal Charitra and Kevin Varilla conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citation that was issued on 6/16/22. LPA Charitra and LPA Varilla met with House Manager, Homer Bautista, and explained the purpose of the visit. On 6/16/2022, the facility was cited for California Code of Regulation (CCR), 87203 Fire Safety. The plan of correction for this citation was due to CCLD by 6/17/2022. On June 30, 2022, LPAs reviewed and verified the plan of correction documents that were provided by the facility and cleared the citation. This report is reviewed and discussed with Homer Bautista. A copy is provided.the state’s words, verbatim · CDSS document, Jun 30, 2022

Type of visit: Case Management - Deficiencies

On June 30, 2022, Licensing Program Analysts (LPA) Komal Charitra and Kevin Varilla conducted an unannounced case management visit. LPA Charitra and LPA Varilla met with House Manager, Homer Bautista, and explained the purpose of the visit. LPA also notified Administrator, Victoria Alejandro via telephone the purpose of the visit. During a plan of correction (POC) visit to the facility on June 30, 2022, LPAs observed 1 staff member and 3 residents. LPAs observed Staff #1 (S1) was not fingerprint cleared to work at the facility. According to the Administrator, S1 has been working at the facility since April of 2022. LPAs reviewed the facility roster and S1 is associated, however does not have fingerprint clearance to be providing care to residents at the facility. This violation results in an civil penalty of $100 per day x 10 days = $1,000 Report is reviewed with House Manager, Homer Bautista and a copy is provided with appeals rights.the state’s words, verbatim · CDSS document, Jun 30, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jul 1, 2022

87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) Violation of this regulation is not met as evidence by: Based on records review, and information collected, it was indicated that Staff #1 (S1) is not fingerprint cleared to work at the facility which poses an immediate health and safety threat to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2022

Plan of correction: Licensee/administrator shall ensure that all employees obtain criminal record clearance and clearance transfer PRIOR to employment or initial presence in the facility. Administrator/Licensee to submit proof of criminal record clearance to CCLD by 7/1/2022. Immediate civil penalty of $1,000 was issued today. $100 x 10 days = $1,000

Type of visit: Case Management - Other

On June 16, 2022, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced case management visit. LPA met with House manager, Homer Bautista and Caregiver, Noel Elizaga, and explained the purpose of the visit. During the complaint investigation 14-AS-20220222094818, LPA Charitra cited the facility for Section 87307(a)(2)Personal Accommodation and Services, as a result of the facility utilizing the garage as a sleeping area for staff. The facility’s plan of correction was to submit a new facility floor plan to CCLD to request for a new fire clearance. On June 13, 2022, CCLD received the fire clearance request back from South San Francisco Fire Department, and it was indicated that sleeping in the garage is not allowed and that all sleeping items must be removed from the garage. During the visit today, LPA observed the couch still in the garage. According to the House Manager, there is still a staff member currently sleeping in the garage. The house manager indicated that the staff member will move all personal belonging in the facility van. In addition, the house manager indicated that the staff will be utilizing the facility van as a sleeping area. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with Homer Bautista; a copy of the report is provided with appeal rights.the state’s words, verbatim · CDSS document, Jun 16, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jun 17, 2022

87203 FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Violation of this regulation is not met as evidenced by: Based on observations and information collected, the licensee did not comply with the section cited above, as the garage was being used by staff for sleeping, which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2022

Plan of correction: Facility will find alternative sleeping area for staff and notify and check with CCLD to ensure it meets CCR regulations.

Allegation investigated: -COVID positive staff member provided care and supervision to COVID negative residents introducing COVID into facility -Facility administrator does not spend required minimum amount of hours at facility -Facility not following program designed

On March 28, 2022 at 8:15am, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver the findings for the above allegations. LPA met with House Manager, Homer Bautista, and explained the purpose of the visit. On January 13, 2021, the Department received a complaint alleging that there was a COVID positive staff (S1) providing care and supervision to COVID negative residents introducing COVID into the facility. According to the complainant, S1 was providing care and supervision to 3 residents. During the investigation, LPA Charitra interviewed staff and it was indicated that S1 was on his/her way to the facility when he/she received postive results. According to the interviewed staff, two staff members who worked NOC shift at the facility abandoned the facility and the residents to avoid coming in contact with S1, therefore the residents did not have a staff member present to provide care and supervision to the resident. The administrator admitted that she allowed S1, who was COVID positive to provide care and supervision to 3 COVID negative residents with full PPE. Based on the interviews and information collected, it was determined that the there was a COVID positive staff providing care and supervision to COVID negative residents introducing COVID into the facility. The preponderance of evidence standard has been met; therefore, these allegations are Substantiated. (CONT. TO 9099C) Substantiated Regarding the allegation that the facility administrator does not spend sufficient amount of time at the facility, according to the complainant, facility administrator comes to the facility sporadically and mainly to deliver groceries, and she divides her time between two facilities; therefore, she is not present at the facility sufficient amount of time required to ensure that the facility operates accordingly. During the investigation, LPA interviewed staff and it was indicated that the administrator is in the facility 2-3x a week or once every two weeks to deliver groceries. Nevertheless, LPA Charitra interviewed the administrator and it was acknowledged that he/she comes to the facility 3x a week for 2-4 hours. Based on LPAs observations and interviews which were conducted, it was determined that the administrator does not spend a sufficient amount of time at the facility to meet the administrator qualifications and duties. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding the allegation that the facility is not following program design, according to the complainant, the facility program design requires a 1:1 care between caregivers and residents; however, there are only two staff members providing care and supervision to 3 residents. LPA Charitra reviewed the plan of operations and verified that the facility submitted and got approved a program design requiring 1:1 staffing provided during most waking hours and two staff providing awake supervision and care during sleeping hours. On January 21, 2022, when LPA Charitra conducted the 10-day complaint visit at the facility, LPA observed 3 residents and 2 staff members, one of which was shadowing that day. This indicates that the facility failed to follow the stated plan of operations. Interviewed staff indicated that since the facility went through a change of ownership, the facility has not been able to meet 1:1 care. According to the Administrator, the facility is trying to hire more staff and is trying to comply to the 1:1 program design but it’s been difficult due to staffing. Nevertheless, the licensee failed to follow the program design in order to meet the resident’s care and supervision. Based on the interviews and documentation, it was determined that the licensee failed to follow the program design and to ensure the proper care and supervision for the residents. Furthermore, the licensee failed to address the staffing concern and find alternative solutions to meet the program design. The preponderance of evidence standard has been met; therefore, this allegation is SUBSTANTIATED. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with House Manager, Homer Bautista, and a copy is provided. Regarding the allegation that the facility administrator provided Licensing with false claims, regarding staffing and resident relocation; On January 12, 2022, LPA Jamie Vado spoke to Administrator regarding the COVID cases at the facility. According to the administrator, the facility at the time did not have any positive residents and there was a sufficient number of staffs to care for the residents. During the exchange, there was a question whether residents had been relocated to accommodate supervision. The Administrator first denied the relocation, and then reported that indeed there had been a relocation. However, during the investigation, staff interviewed, and information collected indicated that the facility has been short on staff but did not relocate the residents at any point. Therefore, based on the information collected, and interviews, the allegation that the facility administrator provided licensing with false claims regarding staffing and resident relocation is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed with House Manager, Homer Bautista, and a copy is providedthe state’s words, verbatim · CDSS document, Mar 28, 2022 · control 14-AS-20220113114225

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Mar 29, 2022

87405(a) Administrator Qualifications: ll facilities shall have a qualified and currently certified administrator… The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section… Violation of this regulation is evidence by interviewed staff indicating that the current administrator will mainly come to the facility to drop off groceries once every 2 weeks or come to the facility sporadically. In addition, LPA Charitra interviewed the administrator and it was acknowledged that he/she comes to the facility 3x a week for 2-4 hours. Nevertheless, administrator has failed to spend a sufficient number of hours in the facility to give adequate attention to the administration of the facility.the state’s words, verbatim · CDSS document, Mar 28, 2022

Plan of correction: Administrator/Licensee shall take refreshment courses and proper training from approved vendors to demonstrate licensee's ability to maintain administrator certificate. Facility Administrator to submit acknowledgement of Title 22 regulation for Administrator Qualifications and Duties.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Apr 4, 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:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Violation of this regulation is not met as evidenced by: According to interviewed staff, it was indicated that there was a COVID positive staff (S1) assisting 3 COVID negative residents at the facility. Additionally, S1 exposed the three residents to an infectious disease, COVID-19, by providing care and supervision to residents in care. Nevertheless, the administrator admitted that she allowed S1 to assist the residents which poses a health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2022

Plan of correction: Administrator/Licensee to submit acknowledgement of Title 22, Regulations for CCR, Personal Rights of Residents in All Facilities 87468, Personal RIghts of Residents in All Facilities

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Apr 4, 2022

Plan of operation: Each facility shall have and maintain a current, written definitive plan of operation... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval… The plan and related materials shall contain the following…Statement of purposes and program goals…Administrative organization, Staffing plan, qualifications, and duties. Plan for training staff, as required by Section 87411(c). Violation of this regulation is not met by facility administrator and interviewed staff indicating that the program design requires a 1:1 care between caregivers and residents; however, there are only two staff members providing care and supervision to 3 residents. Additionally, the interviewed staff indicated that the facility has not been meeting the 1:1 care noted in the program design due to the insufficient number of staff at the facility. Nevertheless, the licensee failed to follow the program design and find an alternative solution to meet the program design.the state’s words, verbatim · CDSS document, Mar 28, 2022

Plan of correction: Licensee/Administrator to follow the program design or find a solution to meet the program design.

Allegation investigated: Facility bathroom is in disrepair Staff is sleeping in the garage

On March 15, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver the findings for the above allegations. LPA was greeted by Administrator, Victoria Alejandro and explained the purpose of the visit. Regarding the allegation that facility bathroom is in disrepair, according to the complainant, the bathroom faucet was broken, and the bathroom shower and toilet were clogged. On February 25, 2022, LPA Charitra conducted the unannounced 10-day complaint visit and observed the three bathrooms in the facility. LPA observed that the faucet was broken in the male’s bathroom. According to the staff, it was indicated that the toilet in one of the bathrooms require multiple flushes if there is a lot of bowel or toilet paper in the toilet. LPA was notified that maintenance was going to come to the facility to fix the toilet. Based on the observations and information collected, it was determined that the facility was in disrepair. Based on this information this allegation is substantiated. (CONTINUE TO 9099C). Substantiated Regarding the allegation that staff is sleeping in the garage, according to the complainant, there is a staff member who sleeps in the garage. During the investigation, LPA interviewed four staff members and it was acknowledged that Staff (S1) does sleep in the garage overnight because he/she does not have a place to live. Additionally, S1 admitted to sleeping in the garage on the couch that converts into a bed and keeps personal belongings in his/her car. Based on the interviews and the information collected, it was determined that S1 has been sleeping in the garage since he/she started working at the facility. Based on this information this allegation is substantiated. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with Administrator, Victoria Alejandro and a copy is provided.the state’s words, verbatim · CDSS document, Mar 9, 2022 · control 14-AS-20220222094818

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 22, 2022

Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Violation of this regulation is evidence by LPA’s observations noted in LIC9099 and the interviews indicating that the facility faucet in the men’s bathroom was broken and that the toilet in the resident bathroom required multiple flushes if there is a lot of toilet paper or bowel in the toilet.the state’s words, verbatim · CDSS document, Mar 9, 2022

Plan of correction: Licensee/administrator to fix the bathroom faucet and toilet in the bathroom and provide LPA with a photo indicating that both have been fixed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(2) · Plan of correction due date: Mar 22, 2022

Personal Accommodation and Services: Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply… Resident bedrooms shall be provided which meet, at a minimum, the following requirements… No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building… Violation of this regulation is evidence by all staff interviewed acknowledged that S1 sleeps in the garage.the state’s words, verbatim · CDSS document, Mar 9, 2022

Plan of correction: Administrator/Licensee to provide LPA acknowledgment of Title 22 Regulations for Personal Accommodation. Administrator/Licensee to submit a new facility floor plan to request for a new fire clearance.

Type of visit: Prelicensing

On 11/29/21 at 10AM, Licensing Program Analyst (LPA), Murial Han met with the Administrator, Roy Johnson to conduct an unannounced Pre-Licensing inspection for change of ownership. LPA Han was properly screened by the Administrator at the entry and LPA observed COVID-19 signs posted by the front entry. The new Administrator, Victoria Alejandro also arrived at the facility for the inspection. LPA observed the indoor and the outdoor passageways are free of obstruction. The Administrator provided a tour of the facility and all the clients were at the Day Program during the inspection. This is a one story facility with 4 private bedrooms. Three rooms are occupied. The client's rooms, the living room, the kitchen, the shower room, the bathrooms and the dining room are well maintained and appeared to be cleaned. The overall facility temperature was measured at 72 degrees Fahrenheit (F). the hot water temperature was measured in the half bathroom, shower room and the kitchen were at 115- 118 degrees F. The laundry room was cleaned and chemicals were locked. The medication storage was locked and inaccessible to the residents. The Carbon Monoxide detectors were present and properly operated. The first aide kit was inspected and equipped. Food supplies were observed to be adequate. The refrigerator temperature was measured at 34 degrees F and the freezer was measured at -1 degree F. The fire and smoke detectors are observed to be operated properly, the fire extinguishes observed to be adequate, and the Administrator reported that there is no firearms and/or ammunition at the facility. The Activities Calendar, the Resident Rights, the Ombudsman, the House Rules, the Licensing Complaint Poster and the Resident Council Rights are posted. In addition, there are COVID-19 signs to be observed through-out the facility and in the bathrooms. PPE supplies are adequate, facility continues to conducted COVID-19 screening for all clients twice a day and staff once a day upon their arrival. In addition, staff members are randomly tested for COVID-19 every other week. There were no objects obstructing the emergency shut-offs: water, electricity (all locations are labeled) and gas shut-off stations. There are many digital communication devices observed around the facility to improve the communication between clients and staff. Facility sketch accurately reflects the floor plan. Comp III orientation was given to the new Administrator, Victoria Alejandro on 11/29/2021. Pre-Licensing is now complete. Immediate Licensure is recommended pending final approval from the Central Applications Bureau. Exit interview conducted with the Administrator, Roy Johnson and the new Administrator, Victoria Alejandro. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 29, 2021