Augustus Elder Care Home

Type of visit: Case Management - Other

On 1/26/23, LPA Mknelly returned to follow-up from 1/25/23 Annual inspection. LPA followed the department's covid 19 procedures, wore a surgical mask and was screened by staff. LPA informed caregiver of the reason for the visit. On 1/25/23 violations were not cited due to technical malfunction; On 1/25/23 LPA observed: Licensee has not insured that quarterly fire drills are completed and there is a resident with dementia in care. At today's inspection, caregiver presented a Fire Drill report for a 1/25/23 fire drill. However, caregivers were unaware of the drill conducted and Licensee and others stated as participating were not present. The fire alarm in room 3 had a disabled fire alarm that has been removed and not replace. On 1/26/23, LPA observed the smoke alarm in place and operational. Both constitute an immediate risk to resident. LPA observed that issue that repairs had been done to damaged wall, a broken closet slider was removed and beds were rearranged to clear the sliding door fire exit. As a result of this the visits on 1/25/23 and 1/26/23, he following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Audrey Whittaker Brissett. Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 26, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jan 30, 2023

Fire Safety-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met based on observation and statements of 1/25/23 that smoke detectors were inaoperable and repairs were completed after the inspection on 1/25/23. This posed a danger to residentsthe state’s words, verbatim · CDSS document, Jan 26, 2023

Plan of correction: On 1/25/23 the last of the smoke detectors was replaced after several weeks of malfuntion. Neither CCL nor fire was notified. Licensee will submit a plan for notification to CCL and Fire in the case of malfuntion of fire systems to CCL by the POC date of 1/30/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(k)(3) · Plan of correction due date: Jan 30, 2023

Care of Persons with Dementia (k) The following...requirements must be met ...: (3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement was not met based on statements and record review that drills had not been completed for greater that 9 months with a resident with demetia in care. This posed an immediate risk to residentsthe state’s words, verbatim · CDSS document, Jan 26, 2023

Plan of correction: The drill documented for 1/25/23 was found to be insufficient. Licensee will complete an actual drill that includes staff practice of emergency procedures by the POC date of 1/30/22. Proof of drill to be submitted to CCL.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 3/18/22 to conduct a Annual Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. LPA toured the interior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. Administrator arrived at the facility. LPA, Administrator, and Infection control Leader completed the infection control domain and facility was found to be in substantial compliance at this time. Violations were noted yet not recorded due to technical difficulties. LPA will return to issue citations. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jan 25, 2023

The state marks this report as 4 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility did not meet resident's hygiene needs. Facility did not ensure that resident had clean clothing. Facility did not provide resident mobility outside of bed. Facility did not allow resident to have visitors outside of designated hours. Facility did not manage resident's medications properly.

On 9/15/22, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met house manager. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptom. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical. Additionally, LPA was screened with temperature at the facility. LPA conducted records review and extensive interviews. Including three interviews today. LPA is unable to find and or meet the preponderance, per policy. Statements from caregivers contradicted statements from others known by R1. R1 is unable, due to disability, to report historical information. Roommate of R1 also was unable to report historical Unsubstantiated information. Neither current nor facility caregivers were able to provide contact information for the home health nurse who saw R1 at the facility. R1 had discharged from the facility before the complaint was filed. LPAs were unable to witness if allegations were accurate while resident was in care. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator.the state’s words, verbatim · CDSS document, Sep 15, 2022 · control 25-AS-20220603085534

Type of visit: Case Management - Other

On 2/9/2022 at 12:10 pm, Licensing Program Analyst (LPA) Cassie Yang arrived to the facility unannounced and spoke with Caregiver, Audrey Whittaker Brisse. Caregiver contacted Administrator, Leilani Aragon, who informed LPA that she just left the facility. LPA Yang observed Caregiver to be on the LIC 308. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA was screened by Caregiver, upon entering the facility. The purpose of this inspection was to conduct a records review. Caregiver was unable to locate a copy of the staff roster and staff schedule. Caregiver contacted Administrator who informed LPA there is no physical copy in the personnel file. Administrator stated she will email one as soon as possible to LPA once completed. LPA requested for Administrator to send a copy of staff roster and the weekly staff schedule by end of the week, 2/11/2022. No deficiencies are being cited as a result of today's inspection. LPA Yang reviewed this report with Caregiver and provided a copy.the state’s words, verbatim · CDSS document, Feb 9, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced on 2/2/2022 to conduct a required annual. LPA met with Audrey Whittaker Brisse, Caregiver, and explained purpose of inspection. LPA completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive COVID-19 diagnoses. LPA were screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Caregiver contacted Leilani Aragon, Administrator, who informed LPA she cannot make it at this time. Administrator informed LPA that Caregiver, Audrey Whittaker Brisee, will be available to tour the facility with LPA. LPA observed (3) residents in the common area and (3) residents in their private rooms. The facility has an approved mitigation plan. LPA and Caregiver toured the interior of the facility, including (4) private resident rooms, (2) common restrooms, kitchen, laundry, garage, and common areas. LPA observed it to be clean and in good repair. LPA observed required postings throughout in the facility. Inside temperature was observed to be 67* F. Fire extinguisher last serviced 11/15/2021. LPA observed sufficient 2+day perishable and 7+day non-perishable food. LPA observed paper towels, soap, sanitizer and hand washing posters in the restrooms. LPA advised Caregiver to have trash can with lid in common restrooms. LPA observed ample PPE and medication supply located in secured areas. Sharps, Toxins and medications were secured. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Caregiver discussed vaccination status of residents and staff as well as visitation protocols per PIN 22--04. LPA reviewed records of Administrator Certificate and Certificate of Liability Insurance. Facility records were found to be current. LPA and Caregiver completed the infection control domain together and facility was found to be in compliance at this time. LPA requested an updated copy of LIC 308 by 2/4/2022. No deficiencies are being cited as a result of today's inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Feb 2, 2022

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 08/05/2021 to conduct a Required 1 - year annual inspection. Prior to visit LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Denise Hall, staff, upon entering the facility. Staff, Audrey Whittaker contacted Administrator and made him aware of LPA's presence and purpose of the visit. Administrator appointed staff (S2) to tour with LPA due to their absence. LPA toured the facility with S2, areas inspected include but are not limited to the following: facility living room, dining room, kitchen, backyard, garage, laundry room, resident bedrooms and bathrooms. LPA observed the facility to be clean, odor free and in good repair. LPA observed knives, cleaning supplies and medications locked and inaccessible to residents in care. LPA observed a sufficient supply of 7 day nonperishable food items and 2 day perishable food items. LPA observed an adequate supply of PPE. LPA found the fire extinguisher to be last serviced on 1/1/2021 and fully charged. LPA found resident bedrooms to have required furniture and sufficient lighting. LPA found the bathrooms to have required grab bars and nonskid shower surface. LPA measured the water temperature to be 105.5 degrees F. S2 tested the smoke detectors and carbon monoxide device and LPA observed both to be in working order. First aid kit was found to be complete. LPA observed one (1) resident in care to be using oxygen but did not find an "oxygen in use" sign posted. LPA reviewed a sample of one (1) resident record and was found to be current and complete. LPA reviewed two (2) hospice care plans for two (2) residents in care receiving hospice services. Hospice care plans were found to be sufficient. LPA reviewed two (2) staff files and found staff files to be current and complete. LPA conducted a medication audit for one (1) resident and found no errors. As a result of today's visit, a deficiency is being cited and can be found on LIC 809-D, per California code of regulations, title 22. Exit interview conducted, copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 5, 2021

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Melana Llopis arrived unannounced at the facility on 08/05/2021 and conducted an annual inspection. Inspection report can be located on LIC809 - Visit date 08/05/2021- Annual/Random.the state’s words, verbatim · CDSS document, Aug 5, 2021