Bristolwood Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Annual inspection visit and met with licensee (LCN) Cindy Chen. LPA observed the facility is temporary on an non operational status..No residents were observed in the facility. LPA toured the facility with LCN including resident rooms and backyard. LCN stated the facility is still under interior renovation and there is no residents in the facility.. LCN stated the facility will update CCL office for the status of the facility. LCN stated the facility is planing to operate on 11/01/2026. No citation noted today. Exit interview was conducted with LCN. The report was provided to LCN for review and signature. A copy of the report was provided to LCN.the state’s words, verbatim · CDSS document, Sep 11, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management for a Non-Compliance Plan Visit and met with Administrator (ADM) Donna Lagman. LPA observed the facility is temporary on an non operational status.. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an Noncompliance Conference meeting held on 9/19/2024. LPA toured the facility with staff ADM including resident rooms and backyard. ADM stated the facility is still under interior renovation. ADM stated the facility will update CCL office for the status of the facility. The case management of inspections will be conducted every 3 months for 2 years. No citation noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Administrator (ADM) Donna Lagman. LPA toured the facility inside out with ADM. ADM stated all residents were relocated. No resident was observed in the facility. The facility is in non operational status. No construction was observed in the facility. ADM stated the facility will have new interior renovation soon. ADM stated the facility plans to reopen on 8/1/2026. Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Apr 14, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Administrator (ADM) Edward Tan. On 01/05/2026, the Department received a death report of resident R1 from the facility. LPA interviewed ADM regarding R1's death. LPA requested R1's physician report, appraisal needs and service, and death certificate. LPA interviewed ADM about the plan of the facility temporary closure on 4/1/2026. LPA reminded ADM to notify the temporary closure of the facility. At this time, the case of R1's death is under review and the Department will conduct a follow up visit if warranted. Exit interview was conducted with ADM. The report was provided to ADM for review. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Jan 30, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management for a Non-Compliance Plan Visit and met with Administrator (ADM) Edward Tan. LPA observed 2 residents and 1 staff in the facility. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an Noncompliance Conference meeting held on 9/19/2024. LPA toured the facility with staff ADM including resident rooms and backyard. LPA reviewed the LIC 500 with ADM. ADM confirmed that the facility has staff cover 24 hours 7 days. LPA observed two storage rooms at backyard. LPA reviewed residents' physician reports, and appraisal needs and service plans with ADM. LPA reviewed residents' medications and centrally stored medication forms with ADM. The reviewed documents are up to date. The case management of inspections will be conducted every 3 months for 2 years. No citation noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management for a Non-Compliance Plan Visit and met with Administrator (ADM) Edward Tan. LPA observed 4 residents and 4 staff in the facility. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an Noncompliance Conference meeting held on 9/19/2024. LPA toured the facility with staff ADM including resident rooms and backyard. LPA reviewed the LIC 500 with ADM. LPA confirmed with ADM that the facility has staff cover 24 hours 7 days. ADM stated S1 is the backup Administrator when ADM is not in the facility. ADM showed S1's administrator certificate. LPA reviewed residents' physician reports, and appraisal needs and service plans with backup Administrator S1. LPA reviewed residents' medications and centrally stored medication forms with ADM. The reviewed documents are up to date. The case management of inspections will be conducted every 3 months for 2 years. No citation noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Nov 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Donna Lagman. LPA observed 5 residents (R1-R5), 3 staff (S1, S2, S3) in the facility. Licensee Cindy Song Chen (LCN) also came to the facility. LPA toured the facility inside and out with ADM. License, Administrator Certificate, and personal rights posters were observed in the facility. LPA reviewed 3 resident file and 3 staff files. Family room, kitchen, dining room, 2 restrooms, a office area, a staff live-in room, 5 resident rooms, and garage were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet was observed locked. Knives closet, and dish washing soap closet were observed locked. Room temperature was at 74 degree F, and hot water temperature was at 114 degree F in facility. Fire extinguisher was serviced on 12/20/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested, and were working. First aid box, and flash lights were observed in the facility. There are 4 bed with bed rail. ADM provided the documents for the 4 residents to use bed rail. Front yard and backyard were inspected. 3 storage rooms were observed at backyard. The fence of the backyard were observed old. LCN stated the facility will upgrade the fence within one month. The last time the facility conducted the emergency and fire drill was on 5/5/2025. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Sep 12, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management for a Non-Compliance Plan Quarterly Visit and met with Donna Lagman. LPA observed 2 staff and 2 residents were observed in the facility. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an Noncompliance Conference meeting held on 9/19/2024. LPA toured the facility with staff S1 including resident rooms and backyard. LPA reviewed the LIC 500 with backup Administrator (S2). LPA observed 1 on-call staff and 1 awake staff on NOC shift which includes the hours of 9pm to 9am daily. LPA reviewed the LIC 500 to observe backup Administrator at the facility. LPA reviewed the caregiver daily log for the April, May, June, and July 2025. Back-up Administrator S2 stated the caregiver daily log was reviewed every Wednesday. LPA reviewed resident progress notes for April, May, June and July 2025. Backup Administrator S2 stated resident progress notes were reviewed and updated every Wednesday. LPA reviewed residents' physician reports, and appraisal needs and service plans with backup Administrator S2. LPA reviewed residents' medications and centrally stored medication forms with ADM. ADM stated he/she reviews all resident's medications on a weekly basis and back-up Administrator S2 reviews the centrally stored medication forms and medication administrator record for accuracy and update. Continue on LIC809-C. Page 1 of 2. The case management of inspections will be conducted every 3 months for 2 years. No citation noted today. Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM. Page 2 of 2.the state’s words, verbatim · CDSS document, Jul 3, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management to conduct a Non-Compliance Plan Quarterly Visit and met with Corporate Officer/Licensee Song Cindy Chen and Corporate Officer/Administrator Donna Lagman. The purpose of the visit is to ensure the facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after an Noncompliance Conference meeting held on 9/19/2024. LPA Rai observed 4 residents and 3 staff at the facilty, including the Corporate Officer/Licensee and Corporate Officer/Administrator. During visit, LPA Rai reviewed the LIC 500 to observe 1 on-call staff and 1 awake staff on shift during the NOC shift which includes the hours of 10pm to 6am daily. LPA Rai reviewed the LIC 500 to observe Corporate Officer/Licensee and Corporate Officer/Administrator shifts at the facility. LPA Rai reviewed the caregiver daily activity log for the month of November. The log included staff checking on the residents every 2 hours in the AM/PM shift and every 4 hours during NOC shift. The log also included the staff turnover system where staff are able to discuss medication administration, Activities of Daily Living (ADLs) provided to the residents, and any emergency that may occur during shift. Corporate Officer/Administrator stated back-up Administrator, Sam Sinio reviews the caregiver daily activity log every Tuesdays, she reviews the logs every Thursdays and Fridays and Corporate Officer/Licensee reviews it every month. LPA Rai reviewed the medication tracking system to ensure all residents have enough supply of medication. LPA Rai observed the tracker documents all the tablets that are in the bottle every day. Corporate Officer/Licensee stated she reviews all resident's medications on a weekly basis and back-up Administrator, Sam Sinio reviews the medication tracking record and medication administrator record for accuracy and update. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. LPA Rai reviewed progress notes for the residents for the months of November and December. Corporate Officer/Administrator Donna stated three staff members are designated to write the progress notes of the residents, which include herself, Corporate Officer/Licensee Cindy and back-up Administrator Sam. Donna stated the three of them will discuss the residents' current condition and review the caregiver's daily activity log and update the resident's Appraisal/Needs and Service Plan as necessary. During today's visit, LPA Rai observed 2 locked cabinets in the kitchen which stored toxins and chemicals inaccessible to residents in care. LPA Rai observed 1 locked cabinet in the bathroom which stored toxins and chemicals inaccessible to residents in care. LPA Rai observed 1 locked storage cabinet in the laundry area which stored toxins and chemicals inaccessible to residents in care. No deficiencies cited per California Code of Regulations, Title 22. This report was reviewed with Corporate Officer/Licensee Song Cindy Chen and Corporate Officer/Administrator Donna Lagman and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 27, 2024

Type of visit: Office

A Noncompliance meeting was conducted on September 19th, 2024 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analyst Simi Rai, Chief Executive Officer Song Cindy Chen, and Chief Financial Officer Donna Lagman. The purpose of the noncompliance meeting was to discuss the history of facility's serious violations cited under Title 22 California Code of Regulations to include Personal Rights, Incidental Medical and Dental Care, Care of Persons with Dementia, Personal Requirements and Administrator Qualifications and Duty. Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2 year monitoring plan by licensing which includes more frequent licensing inspections. The San Bruno Adult and Senior Care - San Jose Unit will refer the facility for legal consultation which may result in administrative actions such as possible Administrator De-Certification, License Revocation, or Employee Exclusion. Deficiencies were cited per California Code of Regulations, Title 22 during today's visit, please see LIC 809-D. Appeal Rights were provided. Report was reviewed with Licensee representatives. A copy of this report, LIC 9111 was provided to Licensee representatives during today's office visit.the state’s words, verbatim · CDSS document, Sep 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87415(a)(1) · Plan of correction due date: Sep 20, 2024

87415(a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. (1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises. This requirement is not met as evidenced by: Based on review of LIC 500, Licensee admitted that on-call night staff is not awake to provide night supervision from 10:00pm to 6:00am, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee to submit a written plan of action to ensure night supervision and update LIC 500 by POC due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR87205(a) · Plan of correction due date: Sep 20, 2024

87205(a)The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement is not met as evidenced by: Based on interview, Licensee admitted that there was no general supervision over the affairs of the licensed facility which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee to submit a written plan of action to ensure supervision over the affairs of the licensed facility and update LIC 500 by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(1) · Plan of correction due date: Sep 20, 2024

87625 (b) (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. This requirement is not met as evidenced by: Based on interview, Licensee and Administrator stated resident R1 was placed in diaper at night instead of scheduled toileting at night with the on-call night staff which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee to submit a written plan of action to ensure a plan is created for resident's tolieting needs by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced continuation of the annual visit and met with Lead Staff, Irish Samantha Sinio. LPA Rai spoke with Licensee (LIC) Cindy Chen and Administrator (ADM) Donna Lagman and stated the purpose of today's visit. Both LIC and ADM informed LPA Rai over the phone they will not be present at the facility during todays visit. LPA Rai observed 4 staff, including Lead Staff and 4 residents at the facility. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed three locked storage unit which was used as storage and not habitual space. LPA Rai observed the laundry machine in the backyard and observed 2 laundry detergents and 5 gallons of paint unlocked and accessible to the residents Lead Staff removed the items and locked them in one of the storage units. LPA Rai observed 1 resident smoking in the backyard who has neurocognitive disorder and was not supervised. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies. LPA Rai toured 6 bedrooms, out of which 4 bedrooms are occupied by residents and 2 bedrooms are occupied by staff. The resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai observed 2 out of 4 resident had half-bed rails attached to the resident's bed. Lead Staff stated the residents do not have signed written physician's order for residents to use half-bed rails for mobility. Lead Staff confirmed the 2 residents are not under Hospice or Home Health services. LPA Rai toured the garage and observed a sofa with blankets and rack of cloths hanging over the soda. Lead Staff states the bed is for lounging for staff and the garage is not used as a bedroom for any person. Continuation on LIC 809-C, Page 1 of 3. Page 2 of 3. LPA Rai observed 3 facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.4 degrees F - 111.4 degrees F. LPA Rai observed the third bathroom located in resident room #5 was not disclosed on the facility sketch. LPA Rai spoke with ADM and LIC regarding the third bathroom in resident room #5 and they both stated the bathroom has been part of the facility since the facility received the license and the facility had not made modification to the physical plant since obtaining the license. LIC stated she will reach out to the City of San Jose and send an updated Facility Sketch to the Department. LPA Rai observed yellow stains on the toilet seat and toilet bowl in the bathroom located in resident room #5.LPA Rai observed dark brown/black stains on the floor near the base of the toilet. LPA Rai observed resident occupying resident room #5 smoking in the backyard. LPA Rai asked Lead Staff regarding the yellow and dark brown/black stains and Lead Staff stated they attempted to clean the stains in the past but were not successful. Fire extinguisher was observed and inspected on 01/05/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. Per review of the records, the last disaster drill was conducted on 01/24/2024 Lead Staff confirmed the facility ADM did not conduct a disaster drill after 01/24/2024. LPA Rai discussed disaster needs to be conducted quarterly according to Title 22 regulations. LPA Rai reviewed resident medications and central stored medication records. LPA Rai reviewed R1's medication with Lead Staff. During observation of R1's medication to R1's Medication Administration Record (MAR), Lead Staff noticed R1's medication #1 did not have medication tablets in the medication bottle. Lead Staff stated they did not refill medication #1 and medication was not available at the facility. During visit, LPA Rai informed Lead Staff to contact the pharmacy to ensure resident's medication is available for pick up. Lead Staff stated to pick up medication on resident's behalf. During review of resident's Centrally Stored Medication Log/Record for all 5 residents and Lead Staff stated to misplaced the documents. Page 3 of 3. During previous visit on 7/12/2024, LPA Rai reviewed staff records, LPA Rai observed the staff records did not contain SOC 341A Statement Acknowledging Requirement To Report Suspected Abuse of Dependent Adults and Elders. ADM was present during visit on 7/12/2024 and when asked, ADM stated "was not aware about the staff signing the document". LPA Rai referred ADM to W&IC 15655 wherein the facility shall provide to all staff being trained a written copy of the reporting requirements and a written notification of the staff's confidentiality rights. ADM stated agreed and understood. 87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs, such as administer medication to residents in care. During audit of the medication, R1 did not have medication which is required to be administered today during bedtime and Lead Staff stated medication can be picked up tomorrow, indicating the medication will be missed today due to medication not available at the facility. After LPA Rai discussed the importance of following physician's orders and During visit, LPA Rai spoke with Licensee/Corporation's President & Secretary (LIC) Cindy Song Chen and Administrator/Corporation's Treasurer (ADM) Donna Lagman. Both LIC and ADM were not available to be present at the facility and informed LPA Rai of the same during telephone conversation. In order to exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves, as discussed in the past, both Licensee and Administrator have to be available and present at the facility 20 hours a week, Monday through Friday 8:00am - 5:00pm. LIC and ADM to submit an updated LIC 500 to reflect the hours of both individuals present at the facility during Monday - Friday. Deficiencies were cited per California Code of Regulations, Title 22 during today's visit, please see LIC 809-D. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Lead Staff, Irish Samantha Sinio and a copy of the report was provided. LPA Rai reviewed this report over the phone with Administrator, Donna Lagman. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jul 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 26, 2024

87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and interview, the facility staff did not have R1's medication #1 refill at the facility during the time of inspection and medication was to be administered at bedtime which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure medication refills are obtained in a timely manner by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Jul 26, 2024

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) ...toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation and interview, 2 laundry detergent containers and 5 containters of paint were located near the laundry mahcine in the backyard accessible to residents which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure toxic substanced are inaccessible to resident by POC due date. Administrator agreed and understood.

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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on observation and record review, bathroom in resident room #5 had yellow stains on the toliet seat/bowel and dark brown/black stains on the floor near the base of the toliet which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure resident's room and bathroom are clean and sanitary and in good repair by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(6) · Plan of correction due date: Jul 26, 2024

87465 Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by: Based on record review, observation and interview, 4 out of 4 resident files did not contain Centrally Stored Medication Log/Record which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure in-service training is provided for medication administrator and accurate record keeping by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 15655 · Plan of correction due date: Jul 26, 2024

W&IC 15655 (a)(1) long-term care facilities, ... shall provide to all staff being trained a written copy of the reporting requirements and a written notification of the staff's confidentiality rights as specified in Section 15633. This requirement is not met as evidenced by: Based on record review and interview, 2 out of 2 staff files reviewed did not contain signed copy of the SOC341 and ADM was not aware of regulation which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure staff review and sign SOC 341A by POC due date. Administrator agreed and understood. During visit on 7/12/2024, ADM provided SOC341A to S1 and S2 and obtained signed copies for staff file.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Jul 26, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be... competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on record review and interview, R1's medication #1 was not refilled and not located at the facility and R1's medication #1 order is to be administered at bedtime which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure staff receive in-service training on medication managment and administration where staff will ensure recordkeeping is accurate by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(1-7) · Plan of correction due date: Jul 26, 2024

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by: Based on record review, interview, and observation, ADM did not ensure resident medication was available to administer and medicaton log was not completed, chemicals were accessible to residents with Dementia, resident room/bedrooms are not in sanitary conditions, fire drills are not conducted everythe state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator stated to follow up with Licensee and submit a written plan of action understanding regulation and and a plan on obtaining training on Title 22 regulations by POC due date. Administrator agreed and understood. (con't) quarter, residents using half bed rails for mobility, without signed written physician's order, staff are not coptentent to provide medication administration to residents, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Aug 1, 2024

87608 Postural Supports (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Based on record review, obserbation and interview, 2 out of 4 residents using half-bed rails for mobility did not have signed written physician's order in resident's file which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure signed written order from physician is obtained when half-bed rails is used for mobility by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(c) · Plan of correction due date: Aug 1, 2024

1569.695 Emergency Plans (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 record review and interview, the ADM conducted last disaster drill on 1/2/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure disaster drill is conducted at least quartely by POC due date. Administrator agreed and understood.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted a 1-Year Required annual inspection visit. LPA Rai met with Staff (S3) Pamela Sinio. S3 stated 3 residents were at the facility and 1 resident was out of the facility. Administrator, Donna Lagman arrived to the facility during the visit. During visit, LPA Rai reviewed 2 resident files and 2 staff files. LPA Rai interviewed 2 staff (S1-S2) and ADM pertaining to the Case Management conducted on 12/28/2023. LPA Rai wanted to clarify information provided during the visit and obtain additional documents to include but not limited to R1's Appraisal/Needs and Services Plan. LPA Rai obtained a copy of current LIC 500, which was updated 1/1/2024. ADM stated the facility night shift (10pm - 6am) is on-call shift and will not be reflected on the LIC 500. ADM stated their Program Plan for staff working night shift (10pm-6am) is on call and the facility does not have awake night staff. LPA Rai will return another day to complete annual inspection. This report was reviewed with Administrator, Donna Lagman and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 12, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) conducted an unannounced case management visit following up on the visit conducted on 12/28/2023. LPA met with Administrator, Donna Lagman and stated the purpose of the visit. On 12/27/2023, the Department received an Incident Report from the facility stating resident (R1) had a fall in his/her bedroom and was transported to the hospital via 911. On 12/26/2023 at approximately 3am, R1 fell in the bedroom and rang the bell for assistance. R1 was taken to the hospital at approximately 9:05am and kept in the Intensive Care Unit (ICU) to monitor breathing and pain. On 12/28/2023, LPA conducted a visit and interviewed 3 staff and requested documentation. Based on the interviews conducted, 3 out of 3 staff stated the facility staff did not seek medical attention right away once R1 expressed pain was uncontrollable at approximately 7am and wanted to go to the hospital. Based on review of phone calls made between S1 and Administrator. S1 stated he/she needs to ask Administrator for permission to call 911 for residents. S1 stated Administrator will make the decision to call 911. At approximately 7:49am & 7:55am, Administrator called and left a voicemail to R1’s responsible party to take R1 to the hospital. At 8:53am, the Administrator texted S1 to call 911 and seek medical attention. The paramedics arrived at the facilty and transported the resident to the hospital at approximately 9:05am. Based on interview with S1 and S2, S2 admitted to sleeping during his/her shift as the awake night staff on 12/26/2023 and did not hear R1’s calling for help. S1 stated he/she was not working and was sleeping when he/she heard R1’s bell ringing. S1 stated he/she woke up S2 to check on R1. R1 had refused to go to the hospital at that time and requested PRN pain management medication. At around 7am, S1 stated that R1 was complaining of pain and S1 tried to contact R1’s responsible party and he/she did not pick up. Based on review of R1's LIC 602A Physician's Report dated 2/13/2023, the resident has diagnosis of Dementia. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. On 1/5/2024, R1 passed away at the hospital. Based on review of the Death Report, the cause of death was complications of rib fractures and unwitnessed fall. Deficiencies were cited per California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. An immediate civil penalty in the amount of $500 was assessed today. Additional civil penalties for the violation resulting in serious bodily injury is pending for further review. This report was reviewed with Administrator, Donna Lagman and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Apr 11, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Apr 12, 2024

87465 Incidental Medical and Dental Care (a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interview and record review, facility staff delayed seeking medical attention for R1 after having a fall at 3am and was in pain &was transported to the hospital at 9:05am which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 11, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure staff are trained to seek timely medical attention by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.2(a)(4) · Plan of correction due date: Apr 12, 2024

87468.2(a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interview,on-call night staff did not respond to R1's call for help; off-duty staff heard and prompted to assist R1 which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 11, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and schedule in-service staff training by POC due date. Administrator agreed and understood.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit regarding an incident report. LPA met with Administrator, Donna Lagman and explained the purpose of the visit. On December 27, 2023, the Department received an in incident report stating resident, R1 had a fall and was transported to the hospital via 911. R1 was in the Intensive Care Unit to monitor breathing and pain. During visit, LPA Rai interview ADM, ADM stated R1 had an unwitnessed fall on 12/26/2023 at approximately 3am when S1 and S2 found R1 on the floor of R1's room. R1 complained of back pain but refused to go to the hospital. At approximately 7am, S1 and S2 check on R1 and decided to send R1 to the hospital via 911/ paramedics. LPA interviewed 2 staff (S1 and S2). LPA requested R1's Progress Notes which were documented starting 6/15/2023 and ending 9/3/2023, R1's Identification and Emergency Information, R1's After Discharge Summary 5/12/2023, R1's Appraisal and staff training pertaining to but not limited to observation of resident and emergency protocols. This case management will be kept open pending investigation. Exit interview was conducted with Administrator, Donna Lagman. A copy of this report was provided to Program Manager, Administrator, Donna Lagman.the state’s words, verbatim · CDSS document, Dec 28, 2023