Atienza Residential Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) E. Conchas made an unannounced visit to the facility. The purpose of the visit was to conduct the required comprehensive annual inspection LPA met with a staff member and was granted entry to the facility. Staff 2 assisted LPA in tour during the visit. At the time of the visit there were two (2) staff present. The facility is a five (5) bedroom, three (3) bathroom home with a kitchen/dining area, living room/activity room. The facility is licensed for a capacity of six (6) residents. The current census is five (5) residents. Licensee arrived shortly after 11:00 am. LPA was still accompanied by staff 2. The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms which are equipped with most of the required furniture. Bathrooms were clean, and appliances were operating appropriately. LPA measured and observed the water temperatures in the bathrooms to be between 112-115 degrees F. The facility is equipped with operating dual smoke detectors and carbon monoxide alarms. Posters such as personal rights,facility sketch, facility license, administrator certificate were posted in a hallway area. LPA observed non-perishable and perishable food supply that was sufficient for the number of residents in care. LPA observed sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated locked storage space for residents/staff files/facility file and medications. LPA reviewed resident files for admission agreements, physician reports, and needs and services plans.Medications/Medication Administration Record (MAR) were audited. Continue to LIC809-C LPA reviewed staff files for First Aid/CPR certification, criminal record clearance and health screenings with Tuberculosis (TB) test result. LPA reviewed facility files for Emergency Disaster plan, Infection Control plan, quarterly drills and liability coverage. The following was observed and cited: · Missing or incomplete infection control plan not available for view. · Staff 1, S2, and S3 did not have completed personnel files including background clearance letters, health screening orientation, dementia care, shadow, initial or annual training and CPR completed. · LPA could not verify liability insurance. · LPA observed Resident 1 and R4 to have missing or incomplete documentation from file. · LPA observed two fire extinguishers expired. · LPA observed a curtain partition nailed to the ceiling dividing the great room from dining area that is not fire clearance approved based on facility sketch. · LPA observed Room 3 and room 4 missing chairs. · LPA observed night light missing in the hallway · LPA did not observe the proper size complaint poster posted. · LPA observed two staff providing care to five residents without a qualified staff member present. · LPA observed tan recliner chair to be torn on the right side. · LPA observed staff 1 to not speak English and was requiring other staff assistance to translate. · LPA observed an incomplete emergency plan procedure. · LPA observed administrator certificate was not current. · LPA observed expired food in pantry, freezer and refrigerator. Continue to LIC 809-C · LPA observed R1 to be residing at the facility with no records or facility agreement for care to be provided. · LPA observed R4 have an incomplete admission agreement · LPA did not observe drills to be completed at facility for each shift · LPA observed bed rails in R1, and R4 bedrooms are in use without physician orders. Based on the observations made during today’s visit, 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 along with an Appeal Rights were discussed and provided to Administrator Caroline Armstrong.the state’s words, verbatim · CDSS document, Aug 18, 2026

Allegation investigated: Licensee does not ensure facility have a certified administrator Resident sustained an injury while in care Staff did not ensure resident was handled appropriately during a transfer

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Caroline Armstrong and explained the purpose of the visit regarding the allegations stated above. First allegation: Licensee does not ensure facility have a certified administrator. Regarding the allegation stated above, LPA conducted a walkthrough of the facility and observed administrators’ certificates to be posted. Upon review of records LPA observed Administrator Certificate to have an expiration date of 5/26/2021. LPA conducted an interview with Facility Administrator regarding the alleged allegation Administrator informed LPA that a current Administrators Certificate has yet to be issued. LPA conducted an admin certificate search through department website and discovered that the current Administrator is listed under the pending certificate list and not listed under the active Administrators list. Substantiated Second allegation: Resident sustained an injury while in care. Regarding the allegation stated above, LPA conducted an interview with Resident #1 responsible party (RP), regarding the alleged allegation RP indicated to LPA that Resident #1 had unexplained bruise and a scrape on their right ankle. RP provided images of R#1 injury and indicated that R#1 is listed as non-ambulatory and requires assistance in transferring in and out of bed and dressing. LPA conducted an interview with Staff #1 who informed LPA that staff did not report R#1 injury and indicated that injury could have happened during the time staff was assisting R#1 with transfer. Third allegation: Staff did not ensure resident was handled appropriately during a transfer. Regarding the allegation stated above, LPA conducted an interview with Resident #1 responsible party regarding the alleged allegation RP reported to LPA that Resident #1 Preplacement Appraisal listed under services that R#1 was listed as non-ambulatory and required help with transferring. RP reported that while Resident #1 was being transferred, staff did not handle R#1 appropriately which resulted in R#1 to sustain an unexplained injury to R1 right ankle. LPA conducted an interview with Staff #1 regarding the alleged allegation and Staff #1 informed LPA that injury could have happened during the time staff was assisting R#1 with transfer. Based on the evidence gathered during the investigation, the above allegations are Substantiated. A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 Regulations, from division 6, chapter, article 6, is, cited on the attached LIC 9099 D. An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility Administrator Caroline Armstrong the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 29, 2026 · control 56-AS-20260305093912

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87785(b)(d)(1) · Plan of correction due date: Aug 14, 2026

87785 Initial Certification Training Program Vendor and Program Approval Requirements …(b) Any vendor applicant seeking approval of an Initial Certification Training Program shall submit a written request to the Department’s Administrator Certification Section using the Request for Course Approval form LIC 9140 and the Vendor Application/Renewal form LIC 9141. The request shall be signed by an authorized representative of the vendor applicant certifying that the information submitted is true and correct, and contain the following:…(d) A written request for renewal of the Initial Certification Training Program shall be submitted to the Department’s Administrator Certification Section using the Request for Course Approval form LIC 9140 and the Vendor Application/Renewal form LIC 9141, and shall contain the information and processing fee specified in Section 87785(b)….(1) A vendor must have a current approved Residential Care Facilities for the Elderly Initial Certification Training Program in order to renew its Residential Care Facilities for the Elderly Initial Certification Training Program vendorship. This requirement is not met as evidence by: Based on observation and record review, the licensee did not adhere to the regulation listed above by operating a facility without a current administrator’s certificate, which poses an immediate Health, Safety, or Personal Rights risk to people in care.the state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: The Licensee has agreed to read over regulation: Initial Certification Training Program Vendor and Program Approval Requirements. And ensure to pay recertification fees and take the necessary classes to renew Administrators Certification. Licensee will provide LPA with proof of payment and proof of the completion of Admin courses by POC 8/14/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Aug 14, 2026

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….(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 is not met as evidence by: Based on observation and record review, the licensee did not adhere to the regulation resulting in R#1 to sustain an unexplained injury, which poses an immediate Health, Safety, or Personal Rights risk to people in care.the state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: The Licensee has agreed to read over regulation: Personal Rights of Residents in All Facilities. And provide training to all care staff regarding the safety and wellbeing of residents in care. The Licensee will provide LPA with proof of training signed and dated by all staff and shall provide the training to LPA by POC 8/14/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 14, 2026

Personnel Requirements – General 87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidence by: Based on observation and record review, the licensee did not adhere to the regulation resulting in R#1 to sustain an unexplained injury while being transferred, which poses an immediate Health, Safety, or Personal Rights risk to people in care.the state’s words, verbatim · CDSS document, Jul 29, 2026

Plan of correction: The Licensee has agreed to read over regulation: Personnel Requirements – General. And provide training to all care staff regarding the safety precautions when transferring or assisting residents in care. The Licensee will provide LPA with proof of training signed and dated by all staff and shall provide the training to LPA by POC 8/14/2026.

Allegation investigated: Staff are physically unable to meet residents needs Staff are unable to communicate with residents

Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Caroline Armstrong, Administrator and discussed the purpose of the visit. The investigation consisted of LPA observations, pertinent record reviews and interviews with staff and residents. The allegation that Staff are physically unable to meet residents needs. Two (2) staff interviewed stated that they are physically able to meet residents needs. Three (3) residents interviewed stated that staff are physically able to meet their needs. The allegation that Staff are unable to communicate with residents. Two (2) staff interviewed stated that they are able to communicate with the residents. Three (3) residents interviewed stated that staff are able to communicate with them and there are no issues with communication. Unsubstantiated Based on evidence obtained during this investigation, the allegation above 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 was discussed, and a copy of this report was provided to Caroline Armstrong, Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 56-AS-20250404154014

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87465(c)(2) · Plan of correction due date: Apr 29, 2026

87465(c)Incidental Medical and Dental Care …facility staff designated by the licensee shall be permitted to assist the resident with self-administration… (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based LPA observations, interviews and record reviews, Licensee unable specify dates medications were administered. There was no Medication Administration Record (MAR) or any documentation of medications administered. Which poses immediate health, safety to persons in carethe state’s words, verbatim · CDSS document, Apr 21, 2026

Plan of correction: Licensee will obtain Medication Administration Record (MAR) to document when medications are being administered. Licensee will submit proof to LPA by Plan of Correction (POC) due date

Allegation investigated: Staff denied Ombudsman entry into the facility

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Caregiver, Danica Reyes, and informed the purpose of the visit. Licensee/Administrator Caroline Armstrong was informed of the visit by telephone. The investigation consisted of LPA observations and interviews the Licensee/Administrator, staff, and residents. Regarding the allegation, staff denied Ombudsman entry into the facility, interview with the Licensee/Administrator reveals that staff did not know who the Ombudsman was. Staff were to busy to verify the identity of the Ombudsman to grant them entry. Based on the Department's investigation, the allegation above 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. An exit interview was conducted where this report was discussed and a copy was provided with appeal rights to Caregiver Reyes at the conclusion of the visit. Substantiatedthe state’s words, verbatim · CDSS document, Oct 2, 2025 · control 56-AS-20231212113737

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Oct 22, 2025

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11)To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon...this requirement is not met as evidenced by: The Licensee did not comply with section cited above by staff not granting Ombudman entry into the facility; which poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: The Licensee/Administrator shall provide inservice staff training on regulation cited and submit documentation of training to the Licensing Agency by POC due date.

Allegation investigated: Staff hits resident in care Staff are blocking exiting doors for residents to have access to common areas

On 9/19/2025, at approximately 9:10 AM, Licensing Program Analysts (LPAs) Lavette Farlow, and Edith Conchas conducted an unannounced visit to the facility to commence a complaint investigation and deliver the findings. LPAs were greeted and granted entrance at the door by Staff, Danica Reyes, Caregiver. LPAs identified themselves and discussed the purpose of the visit. LPAs also presented themselves to Licensee, Caroline Armstrong, and discussed the purpose of the visit. LPAs conducted interviews with staff and residents, reviewed documents and did a walk-through of the facility. Allegation 1: Staff hits resident in care. LPA Farlow interviewed five (5) staff and four (4) residents. Interview with Residents R1, and R5 revealed that S2 hits residents in care. LPA Farlow interview with staff S1 and S3 revealed that S2 does hit and hug people. S1 stated they have not seen it but was aware of R1 stating it happened. S3 stated S2 does hit people but is not sure if it playful, but the behavior made S3 feel uncomfortable. S3 stated S2 does express behaviors of hitting other when talking. Therefore, this allegation is SUBSTANTIATED. A deficiency will be cited. ***Continued on LIC9099C*** Substantiated Allegation 5: Staff are blocking exiting doors for residents to have access to common area. LPA interviews with staff and residents revealed that staff did not keep the pathway free from obstruction. Interview with S3 revealed S2 would obstruct the passageway with large water bottles. Therefore, this allegation is SUBSTANTIATED. A Deficiency will be cited. Based on the evidence gathered during the investigation, the above allegations are found to be Substantiated. A finding that the complaint is Substantiated means that the allegations is valid because the preponderance of the evidence standard has been met per California Code of Regulations Title 22 are being cited on the attached LIC 9099D). An exit interview was conducted where this report LIC9099, LIC9099-C and LIC9099-D and appeal rights was discussed and provided to Danica Reyes, Caregiver at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 19, 2025 · control 56-AS-20250603100246

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 19, 2025

87468.1(a)Residents in all residential care facilities for the elderly shall...personal rights(3)... free from punishment,.. abuse, or other actions of a punitive nature, such as withholding residents’... interfering with daily living... This is evident by Licensee not... Based on LPA interviews, Licensee did not comply with section cited above by not ensuring R1 was free from physical abuse, which poses a potential health, safety, and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee agree to conduct an in-service training for all staff to ensure residents personal rights and safety are safeguarded at all times. Licensee agrees to provide a statement of acknowledgement with all staff who participated in the training and acknowledgement of understanding of this regaulation and residents personal rights by POC date.

Type of visit: Case Management - Health Checks

On September 19, 2025 Licensing Program Analysts (LPA's) Edith Conchas and Lavette Farlow conducted an unannounced visit to the facility to initiate a Case Management visit Health & Safety check. LPAs identified themselves and discussed the purpose of the visit with Licensee Caroline Armstrong. LPAs interviewed, reviewed and observed two (2) staff and one (1) resident. Residents in care were present during visit. An imminent health and/or safety concerns were observed at the time of visit. LPA observed medications in a small plastic storage container accessible to clients and an additional unlabeled loose pill in another clear opened glass container. A citation was cited. LPAs observed some health and/or safety hazards inside the facility. Upon a tour visit conducted by licensee, LPA observed the licensee had expired non-perishable items such as soup, cereal and rice inside the kitchen pantry. Licensee removed some of the items, A citation was cited. LPAs also observed a hole inside the facility hallway wall adjacent to the entrance to the garage door. A citation was cited. LPAs observed the facility to have sufficient staff present at the facility to provide care which the needs of the residents in care appear to be met during this inspection. An exit interview was conducted and a copy of this report (LIC809, LIC 809-D, LIC809-D and appeal rights) was discussed and provided to Caregiver, Danica Joy-Reyes.the state’s words, verbatim · CDSS document, Sep 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Sep 22, 2025

87555(b) The following food service requirements shall apply:(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food... shall not be accepted, used or retained. This requirement is not met as evidenced by: Based on observation, the licensee had expired non-perishable items. Licensee did not comply with the section cited above in not providing safe and of quality food to 4 out 4 residents which poses an potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee shall be responsible for the regular inspection of the food pantry, including the timely removal and proper disposal of all expired food products and the replenishment of nonperishable food supplies sufficient for one week supply and submit proof of restock by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Oct 3, 2025

87303 Maintenance and Operation (a)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 ...This requirement is not met as evidenced by: Based on observation, LPA observed inside the facility a hole in the hallway wall adjacent to the garage door entrance which poses an potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee will repair the hole and submit proof by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2)(5) · Plan of correction due date: Sep 22, 2025

87465(h)The following requirements...(2) Centrally stored medicines shall be kept in a safe and locked...(5)Each resident's medication shall be stored... No medications shall be transferred...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by making medications accessible to 4 out of 4 residents which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Licensee will conduct an in-serivce training to all staff to ensure an understanding of the regulation cited. In addition, licensee will provide a statement of acknowledgement from all participents involved in the training.

Type of visit: Case Management - Deficiencies

At 2:10 p.m. Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to follow-up on a complaint. LPA rang the door bell and knocked on the door three times. LPA called the facility number and left messages. LPA called Administrator's, Caroline Armstrong's cellphone number and a left message. LPA received a text from the Administrator stating she was sick and cannot open the door. Administrator stated that there is another staff present but is busy and can't answer the door. At around 3:10, Staff Danica Reyes granted LPA entry and stated that they where on break and was unavailable to answer door. A deficiency is being cited in accordance with Title 22 of the California Code of Regulations. An immediate civil penalties is being accessed for refusing LPA entry into the facility. An exit interview was conducted where this report was discussed a copy provided to Staff Reyes with appeal rights at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87755(a) · Plan of correction due date: Sep 8, 2025

87775(a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice..this requirement is not met as evidenced by: The licensee did not comply with the section cited above by not allowing LPA entry into the facility, which poses and immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: The Licensee/Administrator shall review the regulation cited and submit a statement of the understanding of the regulation cited by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Magda Malcore conducted a health and safety visit to the facility. LPA met with Staff, Danica Reyes, and informed the purpose of the visit. LPA observed five (5) residents and two (2) staff at facility. LPA conducted a tour of the inside and outside of facility. The facility has sufficient food supply for residents. Air conditioning and bathroom equipment is running properly. Staff working stated that Adam Barone does not live at the facility. An exit interview was concluded where this report was discussed and a copy provided to staff Reyes at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 5, 2025

Allegation investigated: Staff do not meet a resident's diabetic needs while in care Staff mishandle the resident's medications

On 8/27/2025 Licensed Program Analysts (LPAs),Edith Conchas and Renese Howell- Small conducted an unannounced visit to the facility to commence a complaint investigation. LPAs identified themselves and discussed the purpose of the visit with the Licensee Caroline Armstrong. During today's visit LPAs conducted observations, interviewed two staff, an agency caregiver and one (1) resident. LPA's also reviewed and obtained records. It is alleged that staff do not meet a resident's diabetic needs while in care. An interview with resident 1 (R1) revealed that R1 takes diabetis medication and gets their blood sugar checked in the morning by staff. An Interview with Staff 1 (S1) revealed that insulin was given this morning around 8:00 am. LP reviewed the records and audited medications of R1 which reveleald that several medications that were audited, were not listed on the Centrally Stored Medications list. S1 stated that R1 needs assistance with medication administration and S1 is the only staff that assists R1 with the insulin. Based upon record review, interview and observation, this alllegation is SUBSTANTIATED. It is alleged that staff mishandle the resident's medications. An interview with S1 and staff 2 (S2) confirmed that the hospice agency trained staff on general medications, not on diabetic medications and diet. S1 stated that some of R1's medication(s) have been disconitnued, however, LPA's did not observe any documentation to support this. S2 stated that the S1 places the residents' medication in small cups and designates when they are to be given. S2 does not document the date/time/dosage. LPA's did not observe any documentation that the medication(s) were administered nor any menu avaible for diabetes patients. LPAs observed a single loose pill in R1's basket of medications. Based upon record review, observations and interview, this allegation is SUBSTANTIATED. Substantiatedthe state’s words, verbatim · CDSS document, Aug 27, 2025 · control 56-AS-20250818213803

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Aug 28, 2025

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes... including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with section cited above by not following the physician's order of (R1) which poses an immediate Health and Safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Administrator will conduct a staff training on diabetic diet and needs and submit a plan for diabetic care for R1 by the Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87628(b)(4) · Plan of correction due date: Sep 10, 2025

87628 Diabetes (b) (4) In addition to section 87611, General requirements for allowable health conditions, the licesnee shall be responsible for the following: Providing modified diets...physician as specified in Section 87555 (b) (7). This requirement is not met as evidenced by: Based on interviews and records review, the Licensee did not comply with section cited above by not following and providng a proper diet for clients which poses a Potential Health and Safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Licensee will provide a diabetic menu for staff to follow based on physician orders and conduct a staff training on diabtic needs and submit proof to LPA by plan of correction POC due date.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst's (LPA) Edith Conchas and Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA's met with the licensee, Caroline Armstrong and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) licensed capacity for six (6). The current census is four (4). LPA's was accompanied by the licensee to conduct a general overall inspection, which included, but was not limited to, the following: 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 78 degrees Fahrenheit. Water temperature measured at 116 degrees Fahrenheit. LPA's inspected resident bedrooms; they are equipped with required furniture such as mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA's observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating fire extinguishers, smoke detectors and carbon monoxide combination alarms. Posters such as personal rights, CCL complaint poster, CCL license, ombudsman, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for residents/staff files. Medications were kept in inaccessible to residents. LPA's observed the facility did not have a First Aid manual. A deficiency issued. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. LPA's observed facility is not equipped with a 72 hour emergency food supply for residents, a deficiency was cited. ****Continued 809-C**** Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA observed one (1) staff member working in the facility have criminal record clearance through the department. Record Review: LPA reviewed (2) residents files for admission agreements, updated physician reports, and needs and services plans. LPA observed there was no updated and signed physician's report for two (2) of the residents. Deficiency issued. LPA's also reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA's observed facility did not have a medication log to track medication administered to residents. A deficiency issued. . Based on the observations made during today’s visit, four (4) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809, LIC809C, LIC809D and appeal rights were discussed and provided to Licensee, Caroline Armstrong. .the state’s words, verbatim · CDSS document, Jul 25, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) LaVette Farlow and Edith Conchas arrived at the facility to conduct a case management visit for deficiencies observed during complaint visit for control number 56-AS-20250603100246. LPAs observed, Licensee Caroline Armstrong, did not have chemicals locked and secured and inaccessible to residents in care. LPA's observed during the tour that residents medication was found unlocked and not secured in the following areas; pantry, kitchen cabinets and in the garage in several boxes and bags in plain view and exposed as well as in the refrigerator. LPA's observed sharps in the food pantry unlocked and not secured and accessible to residents. LPA's after doing a records review of 3 residents, LPA's observed 3 out of 3 residents files were incomplete. They were missing signatures on the admissions agreement, physicians report, Needs and service plan, Emergency contact sheets , MARs, Preplacement appraisal information, personal rights, and Telecommunication device notification form. LPA's observed licensee did not have updated LIC 500. The current staff personnel files were incomplete and missing the following documents; Health screening report, TB clearance, Personal Record, Personnel report, Criminal record, verification of training, statement acknowledging requirement to report suspected abuse of a dependent adult or elder. ***CONTINUED LIC809C*** LPA's observed 1 out of 2 staff had not been background or fingerprint cleared to work in the facility. LPA's reviewed the compliance history and observed that the licensee was issued a deficiency on 11/6/2024, for not ensuring a background clearance was completed on present staff prior to working in the facility. This is a repeat violation within the last 12 months. Based on today's observation and interview with caregivers the Licensee is cited for violation of Title 22, California Code Of Regulations. In addition, this violation posed an immediate health and safety risk to resident(s) in care. An immediate Civil Penalty of $600 is being assessed. If the deficiencies are not corrected by the following day or Plan of Correction dates, a civil penalty of $100 per day per violation begins and accrues until corrected. The licensee was also informed that an additional civil penalty may be assessed based on Health and Safety Code 1569.59 See LIC809, LIC809C, LIC809D, LIC421BG and appeal rights were discussed and provided to caregiver Caroline Armstrong. Signature on this report acknowledges receipt of appeal rights. An exit interview was conducted, appeal right discussed and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(1) · Plan of correction due date: Jun 5, 2025

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or.. This requirement was not met as evidence by: Based on interviews with staff #1, LPA's Farlow and Conchas determined that the licensee did not obtain S! criminal backgorund clearnace prior to employment which poses an immeddiate health, safety and personal rights risk to residents in care.Deficiency will be issuedthe state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Staff immediately was removed from facility. The licensee has agreed to obtain background clearance for S1 before allowing S1 to work at the facility and provide proof to LPA of S1 association/ clearance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2)(i) · Plan of correction due date: Jun 6, 2025

87465(h)(2) Centrally stored medication... locked in place that is not accessible to persons other than employees responsible.... (i)Prescription or medication which are not taken with resident upon termination of service...to be disposed of and destroyed by facility...not a resident. Based on LPA's records review and observation, the licensee did not ensure all residents medication was centrally stored and kept safe and locked away and inaccessible to residents in care. LPA's also observed expired medications still in facility as well as medications from previous residents not centrally stored and locked and inaccessible to residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: The Licensee has agreed to ensure all centrally stored medication is kept in a safe and locked place that is inaccessible to residents in care by POC date 6/6/25. All none current residents medications be properly dispose of by 6/19/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d) · Plan of correction due date: Jun 12, 2025

All residents records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Based On LPA's observation and record review licensee did not have updated client files which were missing pertinent documents missing signature on admission agreement, Physician Report, Needs and Service plan and Emergency contact.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee agrees to update client files by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a)(c)(g) · Plan of correction due date: Jun 12, 2025

Licensee shall ensure the personnel records are maintained on the licensee, administrator and each employee... (c)Licensee shall maintain in the personnel records verification of required staff training and orientation.(g) All personnel records... for review Based On LPA's observation and record review licensee did not have updated staff files which were missing Personnel records, health screening report, Criminal record report, verification of trainingthe state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee agrees to update client files by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Jun 6, 2025

Except as specified in subsection (b)the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches tools, sharp objects... locked storage. Based on LPA's observations sharps, knives and chemicals were seen in pantry, garage and bathroom unlocked, not secured and accessible to clients.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee agrees to secure and maintain all sharps, knives, and chemicals in a safe secure locked area innacessible to residents by POC date.

Allegation investigated: Facility staff leave residents in soiled clothing for an extended period of time

On 4/23/2025 at 12:15 PM, Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced visit to the facility to commence a complaint investigation. LPA Serrano was greeted and granted entrance by caregiver Irene Huliselan. LPA discussed the purpose of the visit and the elements of the allegations with administrator Caroline Armstrong. LPA Serrano conducted a quick tour of the facility and interviewed the administrator. Regarding allegation "Facility staff leave residents in soiled clothing for an extended period of time." LPA Serrano interviewed the administrator over the phone to investigate the allegation and LPA learned that the alleged victim does not live in this facility but used to live at the other Atienza facility in Redlands. Previous complaints received 4/2/2025 verified that this facility was vacant and no residents here on the date of the allegation. ****continue on LIC9099C**** Unfounded Based on evidence obtained during this investigation, the allegation is Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with caregiver Irene Huliselan and a copy of this report, LIC9099 was discussed and provided.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 56-AS-20250422082147

Allegation investigated: Staff did not allow ombudsman representative access to the facility Staff did not ensure facility phone was answered

Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA Mann met with Caroline Armstrong, Administrator and explained the purpose of today's visit. The investigation consisted of LPA observations, pertinent document reviews, and interviews with staff. The allegations that staff did not allow ombudsman representative access to the facility and that staff did not ensure facility phone was answered. Caroline, Administrator stated that there was no one at the facility to open the door. There are currently no residents at the facility. The phone number listed on the facility profile is not the correct number. LPA Mann toured the facility with the Administrator Caroline, based on LPA observations there are currently no residents at the facility. LPA informed Administrator that CCL will conduct an in-office meeting at the Regional Office for previous deficiencies. Unfounded Based on evidence obtained during this investigation, the allegation is Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was discussed and a copy of this report was provided to Caroline Armstrong, Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 56-AS-20250402104413

Allegation investigated: Staff accepted Power of Attorney over resident Staff are making medical decisions on behalf of a resident in care. Staff altered a resident's document.

Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Administrator Caroline Armstrong and explained the elements of the complaint.Allegation #1: LPA Prieto obtained documentation that reveals staff member #1 (S1), associated with this facility, became resident #1's (R1) Power of Attorney (POA). An interview with Administrator Armstrong confirmed that S1 did indeed become POA for R1.Allegation #2: LPA Prieto obtained documentation showing that S1 altered R1's POA to include additional services and/or treatments. Administrator Armstrong confirmed in an interview that S1 is making medical decisions for R1.Allegation #3: Documentation (POA) for R1 was obtained, revealing that it was altered to include additional services and/or treatments. An interview with Administrator Armstrong confirmed these alterations.During the time of LPA's visit, there was one other resident in care (R2), who stated that he has his own responsible party who makes decisions related to R2's care. Substantiated Based on staff interviews and the documentation obtained, the allegations that staff accepted Power of Attorney over a resident, staff are making medical decisions on behalf of a resident in care, and staff altered a resident's document, were substantiated. This document, LIC 809, LIC 809D, and appeal rights were discussed with Administrator Armstrong, and a copy was left with the facility.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 56-AS-20241218154749

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(d)(2) · Plan of correction due date: Dec 30, 2024

Safeguards for Resident Cash, Personal Property, and Valuables Except as provided in approved continuing care agreements, no licensee or employee of a facility shall:accept any general or special power of attorney for any such person; This was not met was evidenced by: Documentation was obtained that reveals, staff #1 associated to the facility became POA for resident #1.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Administrator to remove staff #1, as POA for resident #1, and appoint an appropriated POA for R1 by POC date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Dec 30, 2024

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This was not met as evidenced by: Documentation was obtained that reveals, staff #1 associated to the facility became POA for resident #1 and altered such document to provide separate services and/or treatmentsthe state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Administrator to remove staff #1, as POA for resident #1, and appoint an appropriated POA for R1 by POC date

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding complaint #56-AS-20241218154749. LPA Prieto met with Administrator Armstrong, asking for resident records for resident #1 (R1). MS Armstrong was unable to provide records for R1 at time of visit. Armstrong stated that records for R1 are located at a different location. LPA stated to Administrator that regulation requires resident records to be at the facility location for LPA inspection and LPA will be citing this facility during today's visit. This report, LIC 809, LPC 809D and appeal rights, was discussed with Administrator Armstrong and a signed copy was left with the facility.the state’s words, verbatim · CDSS document, Dec 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Dec 30, 2024

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This was not met as evidenced by: During time of visit, Administrator confirmed the records for resident #1 were at a different location and not available for review.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Administrator to provide LPA with a hard copy of resident #1's file for physical review at Licensing office by POC date.

Type of visit: Case Management - Other

On 11/06/2024 at 09:50 AM, Licensing Program Analysts (LPAs) Bernadette Allen and Melody Brown conducted an unannounced Case Management visit. LPAs Allen and Brown met with Licensee/Administrator Caroline Armstrong. However, Licensee/Administrator Armstrong left the facility during the visit due scheduled resident assessment. Approval was given allowing staff member Danica Reyes to sign the report. The purpose of the visit was to conduct an inspection to ensure ongoing compliance with regulations and laws and ensure the health and safety of residents in care. During the visit, LPAs Allen and Brown conducted a quick tour of the facility and reviewed documents. LPAs Allen and Brown observed the following and deficiencies were issued: · LPAs Allen and Brown observed that Resident #3 (R3) does not have the required record of dosages of medications that are centrally stored. · LPAs Allen and Brown observed that the facility does not have a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents. · LPAs Allen and Brown observed that staffs at the facility are not assisting Resident #1 (R1), Resident #2 (R2) and R3 with their self administered medications per their physician’s order as there’s no record at the facility that indicated they are assisting R1. R2 and R3 self administered medication per their physician’s order. · LPAs Allen and Brown observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. · LPAs Allen and Brown observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) does not have the required dementia care training in hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living. · LPAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do nothave the required dementia care training in recognizing symptoms that may create or aggravate dementia behaviors, including, but not limited to, dehydration, urinary tract infections, and problems with swallowing. · LPAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required dementia care training in Recognizing the effects of medications commonly used to treat the symptoms of dementia. · LPAs Brown and Allen observed that Staff #1 (S1), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required training in first aid from persons qualified by such agencies as the American Red Cross. · LPAs Brown and Allen observed that Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required health screening maintained in their facility file. · LPAs Brown and Allen observed that Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required tuberculosis (TB) test and TB test result maintained in their facility file. Deficiency will be issued. Based on interview with Staff #2 (S2) and Staff #4 (S4), LPAs Brown and Allen determined that the Licensee did not obtain S4 criminal background clearance prior to employment. Deficiency will be issued. LPAs Brown and Allen observed the Licensee uses the family room in main common area as the sleeping area for Resident #3 (R3) and the staffs. LPAs Brown and Allen observed Resident #1 (R1) and Resident #3 (R3) Admission Agreement do not have the required signature and signature date of R1 and R3 or their Representative. · LPAs Brown and Allen observed that R3 does not have the required Preplacement Appraisal as evidenced of incomplete Preplacement Appraisal (LIC603) in R3 file. · LPAs Brown and Allen observed that Resident #3 (R3) does not have the required Needs and Services Plan maintained in R3 file. · LPAs Brown and Allen determined based on interview with Staff #2 (S2) that the Licensee did not ensure that Staff #3 (S3) criminal background clearance was transferred to the facility prior to employment. · LPAs Brown and Allen observed that the facility’s not conducting the required fire and earthquake drill at least quarterly. · LPAs Brown and Allen observed that the emergency disaster plan was reviewed annually and not signed by the Administrator or Licensee. Deficiency will be issued. · LPAs Brown and Allen observed that there's no planned activities at the facility for the socialization of residents and not just watching television in the living room. In addition based on interviews with staff and resident 2(R2) LPAs Allen and Brown obtained information that the excluded individual, Staff #6 (S6) was at the facility on 11/3/2024. A deficiency will be issued on 11/6/2024 and an immediate civil penalty of $1000.00 will be assessed for CCR 87777(a)(1)(g) as per documents reviewed the facility was cited for the same zero tolerance violation on 10/1/2024 and within the 12-month period. An exit interview was conducted where this report. LIC809, LIC809C, LIC809D, LIC421IM, LIC421BG and Appeal Rights were discussed and provided to Caroline Armstrong Administrator/Licensee.the state’s words, verbatim · CDSS document, Nov 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(20) · Plan of correction due date: Nov 15, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer .... This requirement was not met as evidenced by: Per Licensee/Administrator Armstrong and Resident #5 (R5) responsible party stated written notice of transfer was not given to them only verbal notification which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provide written notification of the transfer of R5 being moved to a new location in Redlands CA. Licensee has also agreed to provide written statement of understanding of the cited regulation by the POC date of 11/15/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Nov 15, 2024

c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. LPAs Brown and Allen observed Resident #1 (R1) and Resident #3 (R3) Admission Agreement do not have the required signature and signature date of R1 and R3 or their Representative.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provided signed admissions agrements that must be signed by their responsible parties for R1 and R3.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(a)(1) · Plan of correction due date: Nov 15, 2024

(a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. (1) Sufficient information about the facility and its services shall be provided to enable all persons involved in the placement to make an informed decision regarding admission. LPAs Brown and Allen observed that R3 does not have the required Preplacement Appraisal as evidenced of incomplete Preplacement Appraisal (LIC603) in R3 file.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provide the required preplacement appraisal (lic603) for R3 along with a written statement of understanding of the cited regulation by the POC date of 11/15/2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(6) · Plan of correction due date: Nov 7, 2024

87465 Incidental Medical and Dental Care (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility...This requirement was not met as evidenced by: LPAs Brown and Allen observed that R3 does not have the required record of dosages of medications that are centrally stored which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provide all residents required record of dosages of medications that are centrally stored and provide a written statement of regulations by the POC date of 11/7/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(c)(4)(A) · Plan of correction due date: Nov 7, 2024

c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415,..This requirement was not met as evidenced by: LPAs Brown and Allen observed that the facility does not have a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to to schedule a staff to work the night shift and submit an updated staff schedule or Personnel report (LIC500) showing a staff scheduled to work the night shift to LPA Allen on POC due date of 11/7/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 7, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following...:This requirement was not met as evidenced by: LPAs Brown and Allen observed that staffs at the facility are not assisting R1, Resident #2 (R2) and R3 with their self-administered medications per their physician’s order as there’s no record at the facility that indicated they are assisting R1. R2 and R3 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provide updated record of dispensing medications to each resident in care by the poc date of 11/07/2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c) · Plan of correction due date: Nov 15, 2024

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 LPAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provide proof of enrollment/registration for required annual training for all staff members. Licensee has also agreed to provide proof of training signed by all staff members once completed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(3)(A) · Plan of correction due date: Nov 7, 2024

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia .... This requirement was not met as evidenced by:PAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required dementia care training in hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living. which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provide proof of enrollment/registration for required annual training for all staff members. Licensee has also agreed to provide proof of training signed by all staff members once completed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(c)(3)(b) · Plan of correction due date: Nov 7, 2024

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff....This requirement was not met as evidenced by: LPAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required dementia care training in Recognizing the effects of medications commonly used to treat the symptoms of dementia.which poses an immediate health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provide proof of enrollment/registration for required annual training for all staff members. Licensee has also agreed to provide proof of training signed by all staff members once completed.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(e)(2) · Plan of correction due date: Nov 15, 2024

HSC 1569.695 Other Provisions (e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.This requirement was not met as evidenced by: LPAs Brown and Allen observed that Resident #3 (R3) does not have the required Needs and Services Plan maintained in R3 file.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provide a completed copy of R3 current appraisal of resident needs and services plan for resident 3.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(g)(2) · Plan of correction due date: Nov 15, 2024

General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)...This requirement was not met as evidenced by: Based on interview with Staff #2 (S2), LPAs Brown and Allen determined that the Licensee did not ensure that Staff #3 (S3) criminal background clearance was transferred to the facility prior to employment which poses a potential and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to ensure that all staff members are cleared and associated to the facility by providing proof of S3 associated through guardian.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Nov 15, 2024

HSC 1569.695 Other Provisions (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios... This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not conducting the required fire and eathquake drill at least quarterly which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to conduct the required fire and eathquake drill at least on a quarterly basis and provide proof of current fire and earthquake drill by the POC date of 11/15/2024.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(d) · Plan of correction due date: Nov 15, 2024

HSC 1569.695 Other Provisions (d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation ....This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the emergency disaster plan was reviewed annually and signed by the Administrator or Licensee which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provide LPA a current emergency disaster plan that is required to be updated annually and signed by the administrator and provide a copy by the POC date of 11/15/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a)(1) · Plan of correction due date: Nov 15, 2024

CCR 87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participa-tion in planned activities. The activities made available shall include: (1) Socialization...This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's planned activities at the facility for the socialization of residents and not just watching television at the living room which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to provide a schedule of planned activities at the facility for the socialization of residents in care. The licensee has agreed to provide a copy of planned activites by the POC date of 11/15/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a)(2)(B) · Plan of correction due date: Nov 7, 2024

(a) 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...This requirement was not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by using the family room area as the sleeping area for Resident #3 (R3) and the staff, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee has agreed to relocate resident #3 back into bedroom #3 and provide proof that R3 was moved back into the room.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(g)(1) · Plan of correction due date: Nov 7, 2024

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or..This requirement was not met as evidenced by: Based on interview with Staff #2 (S2) and Staff #4 (S4), LPAs Brown and Allen determined that the Licensee did not obtain S4 criminal background clearance prior to employment which poses an immediate health, safety and personal rights risk to residents in care. Deficiency will be issuedthe state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Licensee has agreed to obtain a background clearance for S4 before allowing s4 to work at the facility and provide proof to LPA Allen of association/clearance,

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87777(a)(1)(g) · Plan of correction due date: Nov 7, 2024

(a) The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59. Health and Safety Code Section 1569.58 reads in part:.. (g) A licensee's failure to comply with the department's exclusion order after being notified of the order shall be grounds for disciplining the licensee pursuant to Section 1569.50.This requirement was not met as evidenced by: Based on LPAs and interviews with Caroline Armstrong and resident S1 has been allowed at the facility on 11/3/2024 after receiving an exclusion letter.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee is required to disassociate Adam Baron from gardian and must not allow him into any home licensed by Department of Social Services by the POC date of 11/7/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(c) · Plan of correction due date: Nov 7, 2024

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidence by.. Based on observations and record review the licensee didn't comply with the section above by not ensuring that staff 1, 3, 4.and 5 did not have appropriate training in first aid from persons qualified by such agencies as the American Red Cross.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: The licensee stated that she will have all staff members trained/registered with the required first aid training and provide proof of training/certification on the plan of correction by the POC date of 11/7/2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(a)(11) · Plan of correction due date: Nov 7, 2024

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.this requirement is not met as evidenced by... Based on observation interview and record review the licessee did not comply with the cited section above by not ensuring that staff 4,3,and 5 have the required health screening report maintained in s3,s4 and s5 files which poses an immediate health,saftey ,and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Licensee has stated to obtain S3,4,and 5 medical appointment to complete the required health screening report and submit proof to LPA Allen by the by the POC date of 11/7/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87412(a)(12) · Plan of correction due date: Nov 7, 2024

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General .this requirement is not met as evidenced by Based on observation interview and record review the licessee did not comply with the cited section above by not ensuring that staff 4,3,and 5 have the required Tuberculousis (TB) test and TB test results maintained in s3,s4 and s5 files which poses an immediate health,saftey ,and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Licensee has stated to obtain S3,4,and 5 medical appointment to complete the required Tuberculousis (TB) report and submit proof to LPA Allen by the by the POC date of 11/7/2024.

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Bernadette Allen and Magda Malcore conducted an case management visit based deficiencies on 10/01/2024. LPA Bernadette Allen returned to the facility to have Danica Rayes sign the LIC421BG for immediate $500 fire clearance violation. An exit interview was conducted where this report was discussed and provided to Danica Reyes Caregiver at the conclusion of the visit with appeal rights and LIC421 BG.the state’s words, verbatim · CDSS document, Oct 2, 2024

Allegation investigated: Excluded staff present in the facility

Licensing Program Analysts (LPA) Bernadette Allen and Magda Malcore conducted an unannounced visit to investigate and deliver the findings on the allegation above. LPAs met with Danica Reyes caregiver who was explained the purpose of the visit and allegation. LPAs arrived at the facility approximately at 1:50 PM, LPAs toured the facility and observed Staff 1(S1) who has been excluded from the facility leaving out of the garage side door. The Interviews with residents, staff members, and the reporting party corroborated that S1 has been present at the facility since the exclusion order was issued on 06/03/2024. LPA informed Danica Reyes- caregiver that the licensee will be called in for a non-compliance meeting at the San Bernardino Regional Office. The caregiver and licensee has been informed that S1 needs to be disassociated from all facilities licensed by Department of Social Services. Substantiated Based on the evidence gathered during the investigation, the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalties has been issued for the presence of an excluded person at the facility. An exit interview was conducted where this report LIC9099, LIC9099-C and LIC9099-D was discussed and provided to Danica Reyes Caregiver at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 56-AS-20240924151149

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87777(a)(1)(g) · Plan of correction due date: Oct 2, 2024

(a) The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59. Health and Safety Code Section 1569.58 reads in part:... (g) A licensee's failure to comply with the department's exclusion order after being notified of the order shall be grounds for disciplining the licensee pursuant to Section 1569.50.This requirement was not met as evidenced by: Based on LPAs and interviews S1 has been allowed at the facility after receiving an exclusion letter.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: The licensee is required to disassociate Adam Baron from gardian and must not allow him into any home licensed by Department of Social Services.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Bernadette Allen and Magda Malcore conducted an case management visit based deficiencies observed on July 17, 2024. LPA Bernadette Allen conducted a annual inspection and during this visit, the following deficiencies were observed: During the inspection LPA requested files for staff members Caroline Armstrong and Danica Reyes that could not be provided. LPA also requested files for the resident 1(R1), Resident 2 (R2), Resident 3 (R3) and Resident 4(R4) that could not be provided or was incomplete. Armstrong left for work and allowed Danica to continue inspection process and sign report. Staff Danica Reyes looked through documents, but she was unable to provide any files for staff members or residents. LPA also observed the the licensee has not complied with the requirements for the fire clearance. An immediate civil penalty has been issued. LPA requested Special Incident Reports for R1 and R4 that could not be provided. LPA will inform the licensee Caroline Armstrong that she will be called in for a non-compliance meeting at the San Bernardino Regional office. The licensee Armstrong was not present during today's the visit. An exit interview was conducted and discussed with Danica Reyes- Caregiver and a copy of the report LIC 809, LIC809-C and LIC809-D was provided at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Oct 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Oct 2, 2024

All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant ...... This requirement is not met as evidenced by: Based on LPA observation,and interviews, the licensee did not comply with the section cited above LPA observed R1 in bedroom #3 which was is not cleared by the fire department for non-ambulatory residents.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: The licensee has agreed to relocate the resident in bedroom #3 to a bedroom that has been approved by fire marshalls.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a)-(e) · Plan of correction due date: Oct 1, 2024

The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.This requirement is not met as evidenced by: Based on LPA observation,and interviews, the licensee did not comply with the section cited above LPA request facility files for R1,R2,R3 and R4 that could not be provided or was incomplete for review.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: The licensee has agreed to provide a complete files R1, R2,R3 and R4.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)-(h) · Plan of correction due date: Oct 1, 2024

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (h) All personnel records shall be retained for at least three (3) years following termination of employment....This requirement is not met as evidenced by: During the visit LPA Allen requested personnel files that could not be provided.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: The licensee has agreed to provide a complete file for all staff members eligible to work at the facility by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)-(b) · Plan of correction due date: Oct 1, 2024

(a)-(b)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 ...... This requirement is not met as evidenced by:LPA requested the special incident report (SIR) for R1 that could not be provided during visit.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: The licenss has agreed to provide SIR for the death of R1 by the POC date.

Type of visit: Case Management - Annual Continuation

During the interview with Caroline she was asked how many residents were in her care and she said that she had a census of five (5) which included Adam Barone, but when obtaining files Caroline only had incomplete files for Resident 1(R1),Resident 2 (R2) and Resident 3 (R3). Caroline said that she had to leave and allowed her caregiver Danica Reyes to provide LPA with documents needed and to sign the annual report. LPA observed Resident 1 (R1) in a bedroom that was not approved/cleared by the fire department for non-ambulatory clients in care. Per the approved fire clearance dated 3/30/2023 bedroom #4 is the only room approved for non-ambulatory residents which is currently being used by Caroline Armstrong-Administrator. Medications are kept inaccessible to clients. Overall, the facility is clean and in good repair. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Record Review: LPA reviewed (3) client files for admission agreements, updated physician reports, and needs and services plans .R1, R2 and R3 files were incomplete. LPA attempted to review files for staff member(s) but there were no files available for review. Care & Supervision: Facility had sufficient care staff at the time of annual inspection. The staff members working in the facility had criminal record clearance through the department. The annual inspection was completed on 7/31/2024 and the administrator Caroline Armstrong was called during the inspection. Caroline was asked if Adam Barone was still allowed to reside or allowed to enter the facility since receiving the exclusion letter and she stated Yes and he is being allowed to stay at the home because he is currently a client not a staff member. Caroline was informed that fee's of $100 a day will be assessed from 6/3/2024 until Adam Barone is disassociated from the facility for not complying with the exclusion letter issued on 6/3/2024. Caroline was also informed that disassociation through Guardian is required to clear the plan of correction within 24 hours. Caroline said that she will appeal because Adam is no longer a staff member. Caroline was informed on 7/19/2024 annual fees were required to be paid and has not been as of 7/31/2024. Caroline was issued civil penalties for not paying past due annual fee's. An exit interviewed was conduct where this report was discussed and provided to the Danica Reyes at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 31, 2024

Type of visit: Case Management - Other

On 7/19/2024 Licensing Program Analyst (LPA) Bernadette Allen arrived at the facility to conduct the annual inspection. LPA introduced herself and was allowed entry into the home by support staff Danica Reyes. LPA asked Danica the census and she confirmed four (4). While having a conversation with Caroline Armstrong the administrator LPA observed Adam Barone walking into the main door entrance area. Adam turn around fast going back into room number four (4) located by the front entrance. Caroline was asked why is Adam at the facility, and she said Adam is currently a client. LPA informed Caroline that he was not allowed to be at any facility licensed by California Department of Social Services. LPA asked Adam was he a client and he never responded to LPA’s question, he mumbled something under his breath and left the facility. Caroline was informed again that Adam Barone cannot be allowed to work and/or live in any CCL Licensed facility and should not have contact with residents in any facility licensed by the California Department of Social Services. Caroline was informed that on 6/3/2024 Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced case management visit to the facility and met with her and at that time she was issued an immediate exclusion letter and had agreed that Mr. Adam Barone cannot be allowed to work and/or live in a CCL Licensed facility and not having contact with residents in any facility licensed by the California Department of Social Services. A deficiency was cited during this visit for not ensuring the health and safety of the residents in care by allowing an excluded individual into the facility licensed California Department of Social Services. An exit interviewed was conduct when this report and immediate Exclusion letter was discussed and provided to the Administrator Caroline Armstrong.the state’s words, verbatim · CDSS document, Jul 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87777(1)(g) · Plan of correction due date: Jul 20, 2024

87777- Exclusions (1) Health and Safety Code Section 1569.58 reads in part: (g) A licensee's failure to comply with the department's exclusion order after being notified of the order shall be grounds for disciplining the licensee pursuant to Section 1569.50.This requirement is not met as evidenced by: Based on observation, interview and document review, the licensee failed to comply with the immediate exclusion order issued on 6/3/2024 which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 19, 2024

Plan of correction: The licensee has agreed to contact the excluded individuals responsible parties for relocation of Adam Barone and she will write a statement of understanding of the immediate exclusion letter issued on 6/3/2024 and the regulation cited she was cited for on 7/19/2024.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA's) Bernadette Allen made an unannounced visit to the facility to conduct an annual inspection. At the time of the visit there was on two (2) staff members and (4) residents. LPA met with Danica Reyes- support and Caroline Armstrong who was informed of the purpose of the visit. Caroline said that she had to leave for work and Danica could sign the LIC809. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: The Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient furniture and lighting and is maintained at a comfortable temperature. Posters such as personal rights were posted in a common area. There was enough nonperishable and perishable food for the number of residents in care. The facility has a variety of food available for residents, and a menu was available for review. LPA observed that the food was stored in a safe manner. Sharps are stored in a locked pantry inaccessible to clients in care. The resident’s bedrooms are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. All bathrooms had non-slip mats and were operating in a safe and in good sanitary condition. LPA did observe cleaning supplies, toxins items are kept in a locked cabinet and garage inaccessible to clients in care. Due to time restraints LPA was not able to finish the complete inspection and will return at a later date and time. An exit interview was conducted, and this report (LIC809) was discussed and provided to Danica Reyes at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 19, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced case management visit to the facility. LPA met with Administrator Caroline Armstrong. The purpose of today's visit was to deliver an Immediate Exclusion letter for an individual name Adam Barone to MS Armstrong. The exclusion of Mr Barone is based on a complaint of conduct inimical that has been substantiated. LPA reviewed the exclusion letter with Administrator Armstrong, explaining that Mr Barone is not allowed to be present in the facility. Administrator Armstrong understands this immediate Exclusion and has agreed that Mr Barone cannot be allowed to work and/or live in a CCL Licensed facility and have contact with residents in any facility licensed by the California Department of Social Services. Adam Barone was present during the visit. LPA Prieto hand delivered Immediate Exclusion letter to Mr Barone. No deficiencies were cited this visit. An exit interviewed was conduct when this report and immediate Exclusion letter was discussed and provided to the Administrator Armstrong.the state’s words, verbatim · CDSS document, Jun 3, 2024

Allegation investigated: Staff did not treat resident with dignity and respect. Staff forcefully pulled on resident's body.

Licensing Program Analyst (LPA) Javier Prieto arrives to the facility to initiate a complaint investigation regarding the above allegations. LPA Prieto met with Caroline Armstrong, Administrator, and allowed entry. The investigation consisted of staff and resident interviews and observations. Regarding the allegation that staff did not treat resident with dignity and respect; LPA Prieto obtained video footage of the staff #1 (S1) retrieving resident #1 (R1) for a location outside the facility making statements to him that did not accord dignity in their personal relationships with staff and resident. ***continued on LIC 9099C*** Substantiated Regarding the allegation that staff forcefully pulled on resident's body. ; LPA Prieto obtained video footage of the S1 retrieving R1 for a location outside the facility forcefully pulling R1 by the arms to retrieve and relocate R1 back to the facility. Based on LPA observations, interviews which were conducted and records review, the preponderance of evidence standard has been met. Therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations Title 22 are being cited on the attached LIC 9099D). This report was signed by LPA Prieto and Administrator Armstrong and a copy was left with the facility.the state’s words, verbatim · CDSS document, May 1, 2024 · control 56-AS-20240319125953

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 1, 2024

87468.1 (a)(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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Video footage of the S1 retrieving R1 for a location outside the facility making statements to him that did not accord dignity in their personal relationships with staff and resident.the state’s words, verbatim · CDSS document, May 1, 2024

Plan of correction: Administrator Armstrong stated that S1 will be terminated and disassociated from the facility as of today (5/01/24) and S1 will not be working with residents. Armstrong states an eviction will be issued for 60 to evict. Armstrong to email disassociation as of 05/01/24 to LPA Prieto.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 1, 2024

87468.1 (a)(3) 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..This requirement is not met as evidenced by: Video footage of the S1 retrieving R1 for a location outside the facility forcefully pulling R1 by the arms to retrieve and relocate R1 back to the facility.the state’s words, verbatim · CDSS document, May 1, 2024

Plan of correction: Administrator Armstrong stated that S1 will be terminated and disassociated from the facility as of today (5/01/24) and S1 will not be working with residents. Armstrong states an eviction will be issued for 60 to evict. Armstrong to email disassociation as of 05/01/24 to LPA Prieto.

Allegation investigated: Facility kitchen is not kept clean Staff has inadequate record keeping for the residents

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA Malcore met with Administrator, Caroline Armstrong, and discussed the purpose of the visit. Regarding the allegation, facility kitchen is not kept clean, LPA observed the kitchen clean and odor free. Regarding the allegation, staff has inadequate record keeping for the residents, resident records were complete and available for LPA review. Based on record review, the allegation above 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 with Administrator Armstrong and a copy of this report was provided to the Administrator at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 15, 2023 · control 56-AS-20231212113737

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a) · Plan of correction due date: Jan 5, 2024

(a) Living accommodations and grounds...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. This requirement is not met as evidenced by: Licensee did not comply with section cited above by staff #1 sleeps in the bed located next to dining table; which poses a potential health, safety, and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee/Administrator stated the bed in the dining area will be removed by Hospice today 12/15/23. Licensee/Administator shall submit to the licensing agency a written statement of regulation cited

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visited based on complaint #56-AS-20231212113737 visit conducted on 12/15/23. LPA met with Administrator, Caroline Armstrong, and discussed the purpose of the visit. During today's complaint visit, LPA was in the kitchen conducting an interview with the Administrator. Staff #1 (S1) was sitting in the living room which was located next to the kitchen. LPA observed (2) residents in the living room area. While LPA was asking the Administrator questions, S1 shouted responses to LPA. LPA continued interviewing the Administrator when S1 again shouted responses to LPA. LPA stated to S1 that she was directing the questions to the Administrator. S1 loudly stated "I hate licensing" and said an inappropriate word in front of (2) residents in care. LPA asked S1 if the inappropriate word was directed to her. S1 loudly denied saying the inappropriate word. Administrator told S1 to leave the area. LPA stated to the Administrator that S1 is to leave the facility due to safety concerns for the residents. Administrator told S1 to leave the facility. S1 loudly stated "I'm leaving but I am coming back in 20 minutes!" During LPA's visit, S1 did not return to the facility. LPA reviewed staff files for both staff #1 (S1) and staff#2 (S2). LPA record review revealed that the facility did not maintain staff telephone numbers, education and/or past employment history, and hours of training for both S1 and S2. The Administrator stated S1 had no previous employment history. The Administrator stated that S2 was transferred from another facility and will obtain her training history for licensing review. Based on observations and record review, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. An exit interview was conducted and copies of reports LIC809/LIC809-D with Appeal Rights were provided to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Dec 15, 2023

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(5) · Plan of correction due date: Dec 16, 2023

(a) Residents of residential care...shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings...this requirement is not met as evidence by: Licensee/Administrator did not comply with regulation cited above by staff#1's inappropriate conduct in the presence of residents and Licensing Agency representative when poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee/Administrator shall conduct inservice training with staff on the regulation cited and submit proof of training by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Jan 5, 2024

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not as evidenced by: Licensee did not comply with section cited by S1 and S2 did not have personal telephone numbers, education and/or employment history on file for review; which is a potential health, safety, or personal rights rights to residents in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee shall submit to the licensing agency proof of missing documentation and/or employee application by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(1)(A) · Plan of correction due date: Jan 5, 2024

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (1)The following...shall be documented:(A)For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...this requirement is not met as evidenced by: Licensee/Administrator did not comply with regulation cited above by hours of training for both S1 and S2 were not maintained in facility files; which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee/Administrator shall submit to the licensing agency proof of staff training hours for licensing review.