Atwater Residential Care Facility

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Sarah Hurt and Brianna Miranda conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator, Ahluwalia Surinder, Continual Administrator's Certification expires 01/13/2027. There are currently 3 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector. First Aid kit is on site and complete. LPA's observed one facility window screen with small tear. LPA's observed Resident 1's Centrally stored medication record is not accurate. Water temperature in facility hallway bathroom was tested at 110 degrees. Water temperature in Resident 2's bedroom measured to be 126 degrees. Resident 1 and Resident 3's Appraisal/ Needs and services plan is not updated annually. LPA's observed the exit in Resident 2's bedroom is locked and leads to a staff room. The staff room is not listed on the facility sketch. LPA's observed over the counter medications above in a cabinet unlocked above the facility refrigerator. LPA's observed all purpose cleaner unlocked and accessible under facility kitchen sink. Facilities Infection Control Plan, and Emergency Disaster Plan are not signed as reviewed annually. The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Administrator, Ahluwalia Surinder, and copy of report left at facilitythe state’s words, verbatim · CDSS document, May 11, 2026

The state marks this report as 11 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Sarah Hurt and Vadim Gorbam conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Surinder Ahluwalia, Continual Administrator's Certification expires 01/13/2027. There are currently 5 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector. Water temperature was tested at 113 degrees. First Aid kit is on site and complete. The facilities Infection Control Plan has not been reviewed annually. The facilities Emergency and Disaster Plan LIC610E has not been reviewed annually. LPA's observed cleaner disinfectant in Resident 1's bathroom, and bleach cleaning products in hallway bathroom accessible to residents. Resident 2's bedroom is missing desk lamp. Staff 1 does not have CPR/First aid training. Staff 2 does not have LIC503 Health Screening Report. LPA's observed back patio furniture without cushions, backyard grass is dry and overgrown. LPA's observed two backyard window screens with holes. Resident 3's medication was not properly logged on the Centrally Stored Medication record. The facility is not using designated bedrooms on original facility sketch as listed (office is being used as a resident bedroom.) The facility does not have proof of required disaster drills. The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Administrator, Surinder Ahluwalia, and copy of report left at facilitythe state’s words, verbatim · CDSS document, Apr 29, 2025

Allegation investigated: Staff are denying the residents from going outside due to loose animals

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above. LPA met with facility Facility staff Arlene Ferguson and explained the purpose of today's visit. Licensee Jessica Johnson was not present at the facility during this visit, but did contact LPA Hurt via phone. Regarding the allegation Staff are denying the residents from going outside due to loose animals. LPA's interviewed facility staff 1 on 03/13/2024 who stated the residents do not normally go in the facility backyard because the goats are loose in the area. LPA's observed several goats along with some goat feces, in the backyard loose on the patio near the back facility door. Based on LPA's interviews conducted, and observation the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following Deficiencies are being cited Per Title 22 Regulations, Exit interview conducted with facility staff Arlene Ferguson, a copy of this report along with appeals rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Dec 12, 2024 · control 24-AS-20240311224521

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 26, 2024

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 of residents, employees and visitors. The following requirement has not been met as evidenced by: LPA's observed several goats along with some goat feces in the facility backyard, staff 1 stated the facility residents do not go in the backyard as there is several goats, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: Administrator will provide written plan on keeping facility patio clean, and submit to LPA by POC date of 12/26/2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Sarah Hurt and Brianna Miranda conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility staff Pamela Pinnock, Continual Administrator's Certification for Administrator Lacy Vincent is 04/25/2024. There are currently 4 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Smoke alarms were tested and are operational. The home has a carbon monoxide detectors. Water temperature was tested at 129 degrees. First Aid kit is on site and is not complete. LPA's were not provided access to facility staff or client records. LPA's were not able to determine any resident diagnosis or resident needs as client records are not available. LPA's are not able to review staff training as Personnel records are not able for review. Staff 1 present was not able to provide proof of required First Aid training. Resident 1's Centrally Stored Medication log is not properly maintained, and medications are not being given due to being out. LPA's observed multiple facility window screens with tears and not in good repair. LPA's observed several expired food items in facility pantry. LPA's observed facility Resident 1 outside and needing constant supervision along with 2 other residents present. LPA's observed a sliding lock more than 6 feet high on the inside front door out of resident reach which is a potential fire clearance hazard. LPA's were not able to review facility Disaster Plan 610E or log of quarterly disaster drills. The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Facility Staff Pamela Pinnock and copy of report left at facilitythe state’s words, verbatim · CDSS document, Mar 27, 2024

The state marks this report as 11 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analysts (LPA's) Sarah Hurt and Brianna Miranda conducted a Case Management visit. LPA met with facility Facility staff Lacy Vincent, and explained the purpose of today's visit. Licensee Jessica Johnson was not present at the facility during this visit, but did contact LPA Hurt via phone. LPA's requested a current facility resident roster. LPA's requested the current Needs and Services Plan, and Physician's Report (LIC602) for all current facility residents. Staff 1 has not been associated to the current facility. Staff 2 is not background/fingerprint cleared. Exit interview conducted with facility staff Lacy Vincent, and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 14, 2024

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or The following requirement has not been met as evidenced by: Staff 1 is not associated to this facility in LIS or guardian, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 13, 2024

Plan of correction: Licensee will submit LIC 9182 form to associate Staff 1 to the facility, and send proof to LPA by POC date of 03/14/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(b) · Plan of correction due date: Mar 14, 2024

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. The following requirement has not been met as evidenced by: Staff 2 is not background cleared and has been providing care to residents for one month, which poses an immediate, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 13, 2024

Plan of correction: Licensee will remove staff 2 from the facility, and staff will no longer provide care to facility residents until cleared and associated to the facility.

Allegation investigated: Facility is not adequately staffed resulting in the facility calling the fire department for assistance. Facility staff engaged in a verbal altercation with a resident. Facility staff left resident in urine soaked clothing for an extended period of time.

Licensing Program Analysts (LPA's) Sarah Hurt and Brianna Miranda conducted an unannounced visit to the facility to deliver investigation findings. LPA’s met with Assistant Administrator, Airen Miro and explained the purpose of today’s visit. Regarding the allegation the facility is not adequately staffed resulting in the facility calling the fire department for assistance. Emergency Medical Personnel provided a log with more than 21 dates listed where they have been asked to assist Residents in the facility that have fallen, and residents who need assistance getting up from being seated in a recliner to different areas of the facility. Based on interviews conducted during this investigation, and call logs reviewed the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Continued... Substantiated Regarding the allegation Facility staff engaged in a verbal altercation with a resident. Witness 1 stated they were called to assist at the facility, when they arrived they spoke with a facility caretaker who requested they take the resident’s phone. Witness 1 stated they spoke with the resident, who seemed to be coherent and was just saying they didn’t want to be at the facility because they weren’t being treated right and they wanted to go to the hospital. Witness 1 stated they witnessed the caregiver trying to rip the phone from the resident’s hand. Witness 1 stated caregiver then made a phone call and then the caregiver stated the Resident’s daughter told the caregiver to take the phone away from the resident. Witness 1 again stated they weren’t going to take the phone away as it was the residents’ only line of communication. Witness 1 stated they then witnessed the Emergency Medical Services (EMS) staff take the phone away from the resident and the caregiver then came and picked it up where EMS staff set it down. Based on interviews conducted during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Regarding the allegation Facility staff left resident in urine-soaked clothing for an extended period of time. LPA Hurt conducted interviews with several witnesses who stated they observed residents in clothing that appeared to be soaked in urine for extended periods of time. Based on interviews conducted during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. The following deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Assistant Administrator, Airen Miro, and a copy of this report along with appeals rights provided.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 24-AS-20230612142552

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 25, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. 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. The following requirement has not been met as evidenced by: Facility staff frequently called local fire staff to assist with lifitng, and moving facility residents, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Licensee will put a plan place to be in compliance with regulation 87411(a), and copy will be sent to LPA by POC due date of 01/25/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a) · Plan of correction due date: Jan 25, 2024

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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirement has not been met as evidenced by: Facility staff engaged in a verbal altercation with facility resident which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Licensee will put a plan place to be in compliance with regulation 87468.1(a), and copy will be sent to LPA by POC due date of 01/25/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87265(b)(3) · Plan of correction due date: Jan 11, 2024

87265 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:87265 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.. The following requirement has not been as evidenced by: Based on interviews conducted facility residents are being left in urine soaked clothing for extended periods of time, which poses an immediate, health, safety, or personal rights risk to reisdents in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Licensee shall provide documentation and training on how staff will evaluate residents regularly to ensure skin breakdown is not occurring and submit proof to LPA Hurt by POC date 01/11/2024.

Allegation investigated: Illegal Eviction Residents conservator not provided Admission Agreement within seven days

Licensing Program Analysts (LPA's) Sarah Hurt and Brianna Miranda conducted an unannounced visit to the facility to deliver investigation findings. LPA’s met with Assistant Administrator, Airen Miro and explained the purpose of today’s visit. Regarding the allegation Illegal Eviction. Resident 1 was taken to the hospital on 12/17/23 and was denied admission back to the facility upon release. Based on LPA's interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Regarding the allegation Residents’ conservator not provided Admission Agreement within seven days. Resident 1’s conservator was not provided an Admission Agreement within seven days of admission to the facility. Based on LPA’s interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Assistant Administrator, Airen Miro, and a copy of this report along with appeals rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Jan 10, 2024 · control 24-AS-20231219084413

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Jan 11, 2024

87224Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph. The following requirement has not been met as evidenced by: Resident 1 was not accepted back into the facility after a visit to the hospital on 12/17/23, which poses an immediate, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Licensee will put a procedure in place to prevent future unlawful evictions, and copy will be sent to LPA by POC due date of 01/11/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a)(c) · Plan of correction due date: Jan 24, 2024

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (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. The following requirement has not been met as evidenced by: Resident 1's Conservator was not provided Admission Agreement within 7 days of living at the facility which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Licensee will put a procedure in place to be in compliance with regulation 87505(a)(c), and copy will be sent to LPA by POC due date of 01/24/24.

Type of visit: POC

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced POC visit with facility Assistant Administrator Airen Miro to verify correction of citations issued during the visit conducted on 12/01/2023. Deficiency cited on 12/01/2023, Deficiency Section 87507(g)(3)(C) Any fee that is charged prior to or after admission, shall be clearly specified has not yet been cleared. Licensee has not complied with the terms of the POC by POC due date of 12/15/2023. Civil Penalty for failure correct will be assessed during this visit. Exit interview conducted with Assistant Administrator, Airen Miro and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 28, 2023

Allegation investigated: Staff refused to allow resident to return to facility after hospital stay

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint on the allegations listed above. LPA met with facility staff Andrene Lowe and explained the purpose of today's visit. Licensee Jessica Johnson was not present at the facility during this visit, but did contact LPA Hurt via phone. Regarding the allegation Staff refused to allow resident to return to facility after hospital stay. Licensee stated Resident 1 did not sign an Admission Agreement and no money was collected therefore was never a resident at this facility.LPA Hurt observed Resident 1 not to be present at the facility during visit on 12/08/2023. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficincies cited Per Title 22 Regulations. Exit interview conducted with Administrator Jessica Johnson vis phone, and a copy of this report provided. Report signed by staff Present Andrene Lowe. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 8, 2023 · control 24-AS-20231204154208

Allegation investigated: Staff did not issue a refund

Licensing Program Analysts (LPA's) Sarah Hurt and Brianna Miranda arrived unannounced to deliver findings on the above allegatuons on 12/01/23 at 10:00 a.m.. LPA's met with facility Assistant Administrator Airen Miro and stated the purpose of the visit. Regarding the allegation Staff did not issue a refund. Resident 1 provided proof of two paid fees to Licensee totaling $1,855.00 in two separate payments dated on 08/01/2022 (Admission fee $500), and on 08/16/2022 (holding fee $1,355.00.) Resident 1 never moved into the facility. Licensee refunded Resident 1 $500 of the fees paid. The Admission Agreement does not speak to any non refundable "holding" fees. Based on records reviewed during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. The following deficincies are being cited Per Title 22 Regulations. Exit interview conducted with Assistant Administrator Airen Miro, and a copy of this report provided. Substantiatedthe state’s words, verbatim · CDSS document, Dec 1, 2023 · control 24-AS-20230511143721

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(C) · Plan of correction due date: Dec 15, 2023

Section 87507(g)(3)(C) Any fee that is charged prior to or after admission, shall be clearly specified. **This requirement was not met as evidenced by review of the admission agreement provided to RP, that did not specify a $1,355.00 holding fee.the state’s words, verbatim · CDSS document, Dec 1, 2023

Plan of correction: Licensee will submit proof of refund of the $1,355.00 holding fee to the RP by 12/15/23 POC date.

Type of visit: Case Management - Other

Licensing Program Analyst's (LPA) Sarah Hurt and Darius Williams conducted an unannounced Case Management visit. LPA's met with facility Assistant Administrator, Airen Miro and explained the purpose of the visit. LPA's toured the facility including facility including kitchen, indoor, and outdoor areas. The facility has sufficient food supply, and is clean in good repair. LPA's observed two facility staff present assisting residents. LPA's observed one facility care staff cleaning the facility, and doing residents laundry. LPA's discussed a plan with facility Assistant Administrator for the backyard seating arrangement. No Deficiencies cited today Per Title 22 Regulations. Exit interview conducted with facility Assistant Administrator, Airen Miro and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 6, 2023

Allegation investigated: Staff did not meet a resident's incontinence needs while in care Staff did not prevent a resident from causing harm to other residents Staff did not properly reports incidents involving a resident Staff are not providing adequate care and supervision to a resident Staff mishandled a resident's medication while in care Staff is not following the admission agreement

Licensing Program Analysts (LPA's) Sarah Hurt and Darius Williams conducted an unannounced visit to the facility to deliver investigation findings. LPA’s met with Licensee Jessica Johnson over the phone and explained the purpose of today’s visit. Regarding the allegation, Staff did not meet a resident's incontinence needs while in care. LPA Hurt observed several photos documenting Resident 1’s buttocks area to be extremely red and irritated. Medical records document Resident 1 had erythema and pain in the buttocks area. Based on records reviewed during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Continued.... Substantiated Regarding the allegation Staff did not prevent a resident from causing harm to other residents. Incident Report dated 03/13/2023 documents Resident 1 assaulted two other facility residents. LPA Hurt reviewed several text and email exchanges between facility Administrator and Resident 1’s Responsible Party documenting incidents of Resident 1 hitting other facility residents. Based on records reviewed the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Regarding the allegation Staff did not properly report incidents involving a resident. LPA Hurt reviewed medical records documenting Resident 1 was taken to the hospital on 02/06/2023, this incident was not reported to State Licensing. LPA Hurt observed text messages dated March 4, 2023 documenting Resident 1 assaulted another facility resident. This incident was not reported to State Licensing. This incident from March 4, 2023 was not reported to State Licensing. Based on records reviewed during this investigation the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Regarding the allegation Staff are not providing adequate care and supervision to a resident. LPA Hurt reviewed Incident Report dated 03/13/2023 documents Resident 1 assaulted two other facility residents. Staff 1 stated at times working alone with 4 residents providing all care and supervision, meals, and incontinent needs made it difficult to provide supervision. Based on records reviewed during this investigation the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Regarding the allegation Staff mishandled a resident's medication while in care. LPA reviewed Centrally Stored Medication log for Resident 1 documenting a medication with a start date of 01/01/2023 with no quantity, date filled, expiration date, or Pharmacy name. The medication is not documented on any Medication Administration Record. It is unclear if this medication was given to Resident 1 at the facility. Based on LPA observation, and records reviewed during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Regarding the allegation Staff is not following the admission agreement. Admission agreement documents under section “Notice of Rate Changes." If the facility rate for basic services changes because the resident’s needed/desired services changes as determined by an appraisal (see resident appraisals / evaluation of your needs), the rate change will occur when the change in service occurs, as long as at least thirty days have passed since the signing of the admission agreement. We shall provide the resident or the representative a written itemized notice of a rate increase after the change in services which will include a detailed itemized explanation of the additional services to be provided. Responsible Party for Resident 1 was not given a detailed itemized explanation of the additional services provided. The invoice provided is not dated. Based on Records reviewed during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. The following Deficiencies are being Cited Per Title 22 Regulations. Exit interview conducted with Licensee Jessica Johnson, and a copy of this report provided. Continued.. Regarding the allegation Resident sustained multiple injuries while in care. Resident 1 did have documented bruising during a visit to his Physician on 02/13/2023. Resident 1 also had documented un-witnessed falls. Facility staff documented Resident 1 was refusing to use his wheelchair, and walker. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time. Regarding the allegation Staff disclosed confidential information. Licensee did text Responsible Party for Resident 1 asking if their contact information can be given to the Responsible Parties of other residents. Resident 1’s Responsible party was not contacted by any other residents Responsible Parties. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time. Regarding the allegation Staff are falsifying a resident's medical records. Facility staff documented Resident 1’s medication given three times daily once at 4 p.m. despite Resident 1 leaving for the hospital at approximately 3 p.m. Facility staff did give Resident 1 his medication as listed on the prescription despite it not being the exact time. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time. Regarding the allegation Staff did not provide an authorized representative access to resident records. LPA reviewed text messages between Resident 1's Responsible Party, and Licensee Jessica Johnson discussing Resident 1's records. Based on these messages it is unclear when the documents were originally requested, and who requested the records. A written request was not given to Licensee requesting Resident 1's records. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time. No Deficiencies Cited Per Title 22 Regulations. Exit interview conducted with Licensee Jessica Johnson, and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 25, 2023 · control 24-AS-20230320135406

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2 · Plan of correction due date: Oct 26, 2023

(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. The following requirement has not been met as evidenced by: Resident 1 attacked several other facility residents which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee will provide training to all facility staff on Care and Supervision of residents, and provide proof to LPA by POC date of 10/26/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 26, 2023

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: (4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Resident 1's Centrally Stored Medication Log lists medications with no quantity which poses an immediate, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee will submit a plan documenting how she is going to ensure residents medications will be refilled, dispersed and provided to residents per physician’s orders by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Nov 9, 2023

§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s represent ative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. The following requirement has not been met as evidenced by: Licensee did not provide Resident 1's responsible party a detailed written breakdown of services provided , and it is not clear when invoice was given, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee will re submit invoice #100 to include a detailed explanation of additional services to provided at the new level of care and accompanying itemization of the charges to CCL by POC date of 10/24/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87265(b)(7) · Plan of correction due date: Oct 26, 2023

87265 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (7) Ensuring that the condition of the skin exposed to urine and stool is evaluated regularly to ensure that skin breakdown is not occurring. The following requirement has not been met as evidenced by: Records, and photos document Resident 1's buttocks area was extremely red and irritated over a period of weeks, which poses an immediate, health, safety or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee shall provide documentation and training on how staff will evaluate residents regularly to ensure skin breakdown is not occurring and submit proof to LPA Hurt by POC date 10/26/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(1)(D) · Plan of correction due date: Nov 2, 2023

87211Reporting Requirements e shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. The following requirement has not been met as evidenced by: LPA reviewed records of incidents on 03/09/2023 that was not reported to State Licensing which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee will submit proof of regulation understanding to LPA Hurt by POC date of 11/02/2023.

Type of visit: Case Management - Other

Licensing Program Analysts (LPA's) Sarah Hurt and Vadim Gorban conducted an unannounced Case Management visit. LPA’s met with facility Licensee Jessica Johnson and explained the purpose of today’s visit. LPA's walked around and toured the facility resident bedrooms, backyard area, kitchen, and common areas. LPA Hurt provided Licensee with Licensing form 311F LPA Hurt provided Licensee with Community Care Licensing / Medications Guide No Deficiencies Cited today Per Title 22 Regulations. Exit interview conducted with Licensee Jessica Johnson, and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 10, 2023