Caleo Bay Alzheimer's Special Care Center

Allegation investigated: Facility staff did not assist resident with meals as needed.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegation noted above. LPA met with Maria Arriaga, Executive Director and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, the investigation consisted of observations, interviews and a review of records. It was alleged that facility staff did not assist resident with meals as needed. On or around 06/20/23, Resident #1 (R1) sustained an injury while at the facility. Per a review of the facility's progress notes, R1 would not eat at times due to reporting being and observed to be in pain or not feeling well. An additional assessment dated 06/26/23 conducted by facility staff notes R1 to need/receive standby assistance and monitoring due to resistance eating or swallowing difficulties. Prior to the injury, R1 would normally eat their meals in the back dining room, which has increased supervision and staff provided cuing. After the sustained injury R1 is noted to refuse to get up for meals, the facility staff would then bring a food tray to R1s room. Per the Executive Director no reports had been received that staff did not provide any residents with Unsubstantiated with feeding as indicated or needed. Per interviews with multiple facility staff revealed corroborated what was documented in R1s progress notes. Which was R1 would eat some days, and would not eat others, but the attempts were made. There is insufficient evidence to corroborate or refute the allegation of facility staff did not assist resident with meals as needed, therefore the allegation is UNSUBSTANTIATED at this time. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, a copy of this report was reviewed and provided along with the 9099C, and appeal rights were given to Executive Director Maria Arriaga.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 18-AS-20231012144558

Allegation investigated: Staff did not safeguard resident's personal items

On 9/29/2023, Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to conduct further investigation into the above allegations. LPA met with Executive Director, Maria Arriaga, who was informed of the purpose of the visit. Regarding “Staff did not safeguard resident's personal items”, it was alleged that the R1’s clothing was misplaced. LPA reviewed R1’s personal property form which stated “declined to file”. According to the admission agreement signed by R1, the facility waives responsibility if the resident uses the laundry equipment at the facility. According to staff and responsible party interviews, the resident was utilizing the facility laundry equipment at this time. Therefore, the allegation is unsubstantiated. An exit interview was conducted with Executive Director, Maria Arriaga where this report was reviewed and provided to them. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 29, 2023 · control 18-AS-20220914185645

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained a fractured femur as a result of staff neglect. Staff did not seek immediate medical treatment for resident. Staff do not inform resident's authorized person of incidents

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to deliver findings on the above allegations. LPA met with Executive Director, Maria Arriaga, who was informed of the purpose of the visit. During the course of the investigation, the department conducted interviews, records reviews and toured the facility. Regarding allegation, “Resident sustained a fractured femur as a result of staff neglect.” It was alleged that Resident #1 (R1) had sustained a femoral fracture at the facility on or around 09/06/2022, and that the injury was caused by caregivers at the facility. Hospital records note R1 was transported to the hospital on 09/09/2022. Radiology Report dated 9/9/2022, revealed R1 was diagnosed with a Displaced Intertrochanteric Fracture of the Right Femur. Substantiated LPA interviewed S4 who stated that staff was documenting when F1 was being given and that staff were providing this for the resident. Therefore, based on the above information LPA was unable to corroborate the allegation that staff was not provided with F1. Therefore, the allegation is unsubstantiated . Findings that are unsubstantiated mean that although the allegation may be valid, the preponderance of the evidence standard has not been met. An exit interview was conducted with Executive Director, Maria Arriaga, where this report was reviewed and provided to them. The department interviewed staff who stated they are assigned a “round” described as an assignment of residents for the day. The staff stated there are six (6) “rounds” with a staff assigned to each “round”. Staff #1 (S1) stated that on 09/06/2022 the facility was “short staffed” and only had four (4) caregivers to cover the six (6) rounds. Staff #2 (S2) confirmed that R1 was one of the residents assigned to their “round” on 09/06/2022. Staff interviews revealed conflicting information. S1 reported they asked S2 to assist with R1. S1 reported they “struggled” lifting R1 to a standing position because R1 was “putting up a fight”. S1 reported R1 had been combative, and after changing had been “tugging” on the staff’s arm and as a result R1 tripped over the floor transition strip in the restroom and fell. S1 reported trying to catch R1, but due to the momentum of the fall, S1 fell “on the side” of the resident. S1 provided conflicting information when they were re-interviewed. S1 later stated they had fallen partially on R1’s body but denied placing their full body weight on R1. Staff interview with witness revealed, S2 assisted S1 with changing R1. It was reported S1 had “rushed” the resident, “pushed” the resident with their hand which caused the resident to trip over S1’s leg and fall onto their back. It was further reported, S1 tried to catch R1 but R1 was “too heavy” and S1 ended up falling with their “whole body” on top of R1’s leg, and R1 immediately screamed. A review of facility progress notes dated 9/6/2023 1:46 p.m, revealed a third version of what occurred, which was that S1 reported that R1 had fallen on their right knee, causing the resident to fall and be injured. A review of text messages starting 9/11/2022 from S1 to S2 revealed S1 making several attempts to convince S2 to “be on the same page” and report that R1 was being combative and fell over the floor transition strip. Based on the totality of evidence, from interviews conducted and records review; the allegation resident sustained a fractured femur as a result of staff neglect, is substantiated. An immediate civil penalty of $500 is being assessed in accordance with Health and Safety Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident is pending and under review by the Department. Regarding allegation, “Staff did not seek immediate medical treatment for resident.” R1 fell on 09/06/2022. Interviews with staff revealed, R1 screamed immediately after the fall. Staff reported seeing R1 in pain with a swollen knee and leg. This incident was reported to Staff #3 (S3) who assessed R1 and then called hospice. Hospice notes dated 9/6/2022 revealed hospice staff assessed R1. A mobile x-ray unit was requested and came out to the facility on 09/07/2022. The x-ray was completed for R1’s knee, as staff were told, R1 fell on their knees. Radiology report dated 9/7/2022 revealed, the x-ray was negative for an injury to R1’s knee. Staff interviews revealed R1 was still observed to be in pain after the x-ray. R1’s POA, then insisted on R1’s foot and hip being x-rayed. Additionally, Staff #4 (S4) documented on facility progress notes 9/8/2022 R1’s upper right thigh in an “awkward” position. On 09/09/2022, a second X-ray was conducted. Radiology report dated 9/9/2022 revealed, the x-ray showed a right femoral fracture. R1’s doctor requested R1 be sent out for possible surgery. A total of five different staff interviews, revealed, they believed R1 was in pain because R1 appeared “pale” in the face and had swelling and redness on their knee and leg. A review of progress notes, dated between 9/06/2022 and 09/09/2022, corroborated that R1 was changed and transferred to and from their recliner and had been observed to be in pain. Therefore, from the time of the fall on 09/06/2022 to 09/09/2022, three (3) days had elapsed where the resident was observed to be in pain and staff did not seek medical attention. Therefore, the allegation is substantiated. Regarding allegation “Staff do not inform resident's authorized person of incidents”, it was alleged that resident had fallen at the facility several times and that the resident’s POA had not been informed about some of the falls when they occurred. LPA conducted a file review of the facility and found that falls documented on hospice progress notes for 6/3/2022, 3/18/2022, 2/24/2022 and 2/21/2022 had not been reported to the department. LPA also found that fall resulting in a femoral fracture on 9/6/2022 had not been reported until 9/14/2022, past the 7-day reporting requirement. It was also found during department investigation that S1 had not given accurate account of events for R1’s fall on 9/6/2022. It was only found during this investigation and through re-interviewing S1 that S1 had fallen on top of R1. Therefore, based on this information the allegation is substantiated Substantiated findings mean that the preponderance of the evidence standard has been met. Deficiencies were cited for substantiated allegations according to the California Code of Regulations Title 22 Division 6 Chapter 8. Plans of correction were documented and created with Executive Director, Maria Arriaga, along with deficiencies on an LIC9099-D page. An exit interview was conducted with Executive Director, Maria Arriaga, where this report along with civil penalty page LIC421IM, LIC9099-D pages, and appeal rights were reviewed and provided to them.the state’s words, verbatim · CDSS document, Sep 12, 2023 · control 18-AS-20220914185645

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Sep 13, 2023

(a) In addition…all of the following personal rights:(8) To be free from neglect…physical, or sexual abuse.This requirement was not met as evidenced by: Based on interviews and records review,S1 was neglectful while changing R1, by pushing R1 and falling on top of R1’s leg resulting in a fracture. This poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 12, 2023

Plan of correction: The administrator agreed to hold an all staff training on 9/21/2023, where staff will be trained on resident, changing, challenging behavior, and personal rights. The licensee agreed to send the training material to the LPA by the POC due date and notify the LPA when the training is completed on 9/21/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Sep 13, 2023

(a) A plan for incidental medical...care shall be developed...(1)The licensee shall arrange, or assist in arranging, for medical...care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and records reviews, R1 did not receive appropriate medical attention for fractured until (3) days after. This was due to S1 disseminating inaccurate statements. This poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 12, 2023

Plan of correction: The administrator agreed to send the LPA training material they will use with staff for emergency scenarios and assessing residents. This will be sent to LPA by the POC due date. The Administrator agreed to send notification to the LPA when the training is completed on 9/21/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87221(a)(1) · Plan of correction due date: Sep 19, 2023

(a) Each licensee shall furnish...(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...This requirment was not met as evidenced by: Based on interviews and records review it was found incident for R1 was reported past 7 days and reported inaccurate occurence to responsible party. This poses an potential health saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 12, 2023

Plan of correction: The licensee agreed to send the LPA a self certified statement on their understanding of reporting requirments and when to report a resident fall. This is due by the POC due date the LPA.

The state marks this report as 9 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 9/12/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility for an unrelated matter. LPA met with Executive Director, Maria Arriaga, who was informed of the purpose of the visit. This report is to document deficiencies found. It was found that Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) were not associated to the facility roster. LPA reviewed the staff schedule for September 2022 and found S1, S2 and S3 are working at the facility. LPA reviewed the department database and found S1, S2 and S3 are all fingerprint cleared. It was documented that S1, S2, and S3 have all worked at the facility for more than 5 days. Therefore, the facility is being cited for the three (3) staff not being associated to the facility. As of today's date, the three staff are no longer employed at the facility. A civil penalty is applied to the deficiency for the maximum amount of $500 per employee. Total civil penalties issued is $1500. Plan of correction was made with Executive Director, Maria Arriaga, and documented. An exit interview was conducted where this report, Civil Penalty assessment LIC 421BG, LIC9099-D page, and Appeal Rights were reviewed and provided to Executive Director, Maria Arriaga.the state’s words, verbatim · CDSS document, Sep 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 13, 2023

(e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility:(2)Request a transfer of a criminal record clearance...This requirment was not met as evidenced by: Based on record review it was found that three staff were not associated to the facility. This poses an immediate health safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 12, 2023

Plan of correction: The administrator stated they send the LPA a self certified statement by the POC due date stating that they have reviewed their roster and understand the process to associate staff to their facility.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Executive Director, Maria Arriage, who was informed of the purpose of the visit. At the time of the visit there was seventeen (17) staff and fifty-two (52) residents present. The facility has a dementia program and approval for locked perimeters with an alarm and signal system. The facility does not have any bodies of water and does not allow firearms on premises. The facility is approved for 20 hospice residents; currently the facility has 15 residents receiving hospice services. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following: Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Physical Plant: LPA observed the resident bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The smoke detector and carbon monoxide was operational, and the hot water temperature 115.9F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Facility receives delivery shipments twice a week and has emergency food prepared. Facility has menus and alternative menus posted for residents. Care & Supervision/Administration: Adequate staff are present for the supervision of residents during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate. Record Review and Resident/Staff Files: LPA reviewed five (5) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. LPA observed five (5) staff not associated with this facility when looking over staff schedule. LPA informed Executive Director Maria and a civil penalty and plan of correction will be issued. Five (5) resident files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: The facility has a medication room, which is kept locked. The dispensing of residents medications is documented on an electronic MAR log and the medication appears to be locked and stored appropriately. The medication room is stocked with first aid supplies as required by Title 22 regulations. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. An exit interview was conducted where a copy of this report was provided to Executive Director Maria Arriaga.the state’s words, verbatim · CDSS document, Jul 17, 2023

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Resident was physically abused while in care.

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced complaint visit to deliver the findings of the above allegation. LPA met with Community Development Director Anthony Aniasco and conducted a tour of the facility. The Department's investigation included interviews with staff and residents and a review of facility documentation. Staff who were interviewed denied causing injury or having knowledge of anyone else causing injuries to Resident One (R1). Interviews with facility residents were attempted but due to cognitive impairment, interviews were unattainable. Unsubstantiated On the night of the incident, R1’s spouse took R1 to the hospital. Medical records document the observance of “small scattered bruises” but indicated “no evidence “of traumatic injuries” as being noted. R1 was unable to be interviewed due recent medical changes that left R1 unable to speak and with a diminished cognitive ability. Law Enforcement responded on the night of the incident and identified two bruises on R1; one on R1’s neck and one on R1’s hand. The deputy indicated the bruises did not appear to originate from an assault. The investigation did not provide corroborating evidence to state the resident was physically abused. Therefore based on the investigation, the allegation that R1 was physically abused while in care is UNSUBSTANTIATED. This means that although the allegation may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violation did occur. An exit interview was conducted and a copy of this report was discussed with and provided to Executive Director Maria Arriaga.the state’s words, verbatim · CDSS document, Nov 9, 2022 · control 18-AS-20220214132232

Allegation investigated: Staff illegally evicted resident Facility did not have hot water

On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPA Colvin met with Adminsitrator Maria Arruaga and informed her of the purpose of today's inspection. Below is a summary of the findings of the investigation: Regarding allegation “Staff illegally evicted resident”: LPA Colvin interviewed Administrator Arruaga and reviewed relevant records to the allegation, such as an email from the Administrator dated 9/14/22, which was the facility's Termination Notice to resident (R1)'s family. The notice states "We became aware that we can no longer meet his needs at Caleo Bay.....Discharge from Caleo Bay will be effective today". LPA Colvin additionally observed staff charting for 9/14/22 memorilizing the same notice. Administrator Arrugua additionally attached the first nine pages of the signed Admissions Agreement in the email. LPA Colvin reviewed this same Admissions Agreement and observed that in accordance with Title 22 Regulations, the Admissions Agreement states that the facility may give a 30-day Notice of Termination if there is an unmet need. Substantiated Additionally, the unmet need must be confirmed/documented through a reassessment of the resident. LPA Colvin observed that the Notice of Termination for R1 did not follow these requirements, as outlined in the Admissions Agreement. Title 22 Regulations does not permit for facilities to evict residents without a 30-day notice, unless a 3-day notice is approved ahead of time by Community Care Licensing. Therefore, based on interviews and record review, the allegation "Staff illegally evicted resident" is SUBSTANTIATED. Regarding allegation "Facility did not have hot water": LPA Colvin observed a staff note in R1's charting on 9/11/22 where a visitor of R1 complained about there not being hot water in Room #46. During today's inspection, LPA Colvin measured the hot water from the faucet in the sink of Room #46, and after waiting for several minutes, observed that the maximum temperature LPA Colvin measured was 92.6. LPA Colvin additionally measured the hot water from the sink faucet in Room #36, and the maximum hot water temperature LPA Colvin read for that room was 86.7. LPA Colvin waited ample amount of time before each final measurements was logged, and observed that prior to reaching their maximum temperature, the climb in degrees was around .1 every 30 seconds. At the time of the final measurements, LPA Colvin had not observed any change in temperature for over 1 minute. Title 22 Regulations requires hot water to be at least 105, but not more than 120. Therefore, while the facility does have the ability to have hot water (based on water temperature being more than that of non-heated water), the hot water coming from the resident faucets (at least in two rooms) is not hot enough according to Title 22 Regulations. Therefore, based on observations, the allegation "Facility did not have hot water" is SUBSTANTIATED, A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Administrator Maria Arruaga during the exit interview.the state’s words, verbatim · CDSS document, Sep 15, 2022 · control 18-AS-20220914185645

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Sep 16, 2022

Additional Personal Rights of Residents in ...Facilities: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents...and shall comply with all eviction and relocation protections for residents.... This requirement was not met by: Based on record review, the Licensee did not comply with the above regulation with one resident (R1). Administrator provided R1's family with an eviction notice on 9/14/22 which was effective immediately. The facility also did not conduct a reassessment of R1. This is an immediate personal rights violation of R1.the state’s words, verbatim · CDSS document, Sep 15, 2022

Plan of correction: Licensee agrees to recind the eviction notice sent to the family, and provide LPA Colvin with a copy of an email sent to the family detailing the recintion of the illegal eviction. This does not prohibit the facility from issuing a 30-day eviction, should the follow the proper procedure. Additionally, Licensee agrees to have Administrator review Title 22 Reglation Section 87224 Eviction Procedures. Administrator to provide LPA Colvin with Self-Certification of completion as well as Statement of Understanding regarding proper eviction procedures. Email, self-certification, and Statement due by 9/16/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Sep 30, 2022

Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care... shall deliver hot water. Hot water temperature controls shall be...a temperature of not less than 105 degree F... This requirement was not met by: Based on observations, the Licensee did not comply with the above regulation with at least two resident bathrooms (#46 & #36). LPA Colvin observed a maximum hot water tempurature in Room #46 of 92.6 degrees, and 86.7 degrees in Room #36. This is a potential health risk for residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2022

Plan of correction: Licensee agrees to adjust the settings on the water heater and re-measure the maximum hot water tempurature in 3 resident bathrooms in each wing of the facility. Licensee to provide LPA Colvin with readings for each room, confirming that the tempurature is inbewteen 105 and 120 in resident bathrooms. Readings to be provided to LPA Colvin by Plan of Correction date of 9/30/22.

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

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Crystal Colvin conducted an unannounced visit to the facility for the purpose of a health and safety check. LPA Colvin met with facility Administrator Maria Arruaga, who was informed of the purpose of the visit. LPA Colvin conducted a tour of the interior and exterior of the facility, and confirmed that the facility has sufficient paper supplies, medications, PPE supplies, staff, and food supplies. No immediate health and safety concerns observed during today's inspection. An exit interview was conducted where this report was reviewed and provided to Administrator Maria Arruaga.the state’s words, verbatim · CDSS document, Sep 15, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Business Office Manager Tammy Eddy and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Business Office Manager Tammy Eddy and inquired about if the facility has an Infection Control Plan that LPA Colvin could view, as there is not one on file with Licensing. Business Office Manager Tammy Eddy provided LPA Colvin with a binder which indicated it contained the Infection Control Plan, but when LPA Colvin looked through the binder, there was only a hand washing guide and training for staff in relation to infection control. Prior to the completion of the inspection, Business Office Manager Tammy Eddy was able to produce the facility's Infection Control Policy, which LPA Colvin quickly looked through. LPA Colvin instructed Business Office Manager to submit a copy to the Riverside Licensing Office for the facility's file. LPA Colvin toured the facility and confirmed that residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels, and hand washing guides are posted. Upon entering the facility, LPA Colvin observed postings for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to be sufficient for a 30-day supply. LPA Colvin went over the various recommended training for facility staff with Business Office Manager Tammy Eddy in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. Business Office Manager Tammy Eddy confirmed that all staff have been fit tested, and that they will be re-fit tested annually. LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Business Office Manager Tammy Eddy confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility, which LPA Colvin confirmed through being screened upon entry as well. LPAs Colvin additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions. Other: LPA Colvin inquired as to who the current Administrator of the facility was, and if the Administrator on file, Ronda WIlkin, still works at the facility. Business Office Manager Tammy Eddy stated that the current Administrator is Maria Arriaga (who LPA Colvin confirmed is associated to the facility) and that Ronda Wilkin is not with the facility any longer (LPA Colvin confirmed this staff is not on the current roster). LPA Colvin requested for the facility to submit an Administrator Packet to Licensing so that the current Administrator can be updated to reflect on the facility's profile, and for the prior one to be removed. An exit interview was conducted with Business Office Manager Tammy Eddy and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 9, 2022

Type of visit: Case Management - Health Checks

On 02/15/2022 at approximately 11:00 am, Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility to conduct a health and safety check. LPA was met with Administrator Sheila Fike and accompanied LPA on a tour of the facility. Currently the facility has 51 residents in care. There are no firearms or ammunition. LPA observed the facility was kept at a comfortable temperature during this visit (75 degrees). The bathrooms are equipped with grab bars and non-skid shower mats (which were rolled up) for residents safety. The bathrooms were in operating condition. The resident bedrooms were furnished with bed, closet space and/or dressers, night stands and lighting. LPA observed the kitchen to be clean and free of odor and food to be stored and prepared in a healthful manner. The kitchen was inspected and noted that food supplies are sufficient to meet Title 22 requirements. The facility has an outdoor area that is shaded with table and chairs for client’s comfort while sitting outside. LPA observed the resident’s medications are centrally located in a nurses' station area and were secured and labeled in compliance with state and federal laws. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted and a copy of this report was reviewed with and provided to Ms. Fike.the state’s words, verbatim · CDSS document, Feb 15, 2022

Allegation investigated: Resident sustained multiple falls due to neglect Resident sustained multiple injuries due to neglect

Licensing Program Analyst (LPA) Deborah Mullen delivered the findings of the above allegations. LPA met with Sheila Fike, Executive Director. The Department investigation included interviews with staff, medical personnel and a review of Resident 1’s (R1’s) records. Interviews with staff revealed R1 had sustained multiple unwitnessed falls. The facilities Health Services Director indicated R1’s doctor had ordered physical therapy and that R1 went through evaluating treatments, gait training, a sensor light in R1’s room was on twenty-four hours a day and R1 was reminded to use a walker. However, interviews revealed, not all staff were aware R1 was a fall risk. Staff interviews also revealed, not all staff were aware of their responsibilities in response to R1’s falls. A review of facility Progress Notes confirmed R1 sustained falls on January 1, 2019, March 3, 2019, March 6, 2019, March 25, 2019, August 29, 2019, September 4, 2019, October 8, 2019 and October 26, 2019. Based on the Department’s investigation there is corroborating evidence to support the allegation that R1 sustained multiple falls due neglect, therefore this allegation is substantiated. Substantiated On October 26, 2019 at approximately 0600 R1 was observed sitting in a chair by the nurses’ station with a blood face and injuries to the lip and eye. R1 was sent to the hospital and was diagnosed with a superficial laceration of the right upper lip with minimal swelling, bilateral lower extremity trace edema, multiple superficial skin tears in the lower extremities, multiple bruises, closed head contusion, closed fracture of multiple ribs of right side, initial encounter and hemopneumothorax on right side. Staff interviews did not provide evidence as to how R1 sustained the injuries. Staff indicated R1 was checked on during the overnight shift, however, no one observed R1 fall, nor did anyone observe how R1 obtained the injuries. Staff interviews indicated residents are to be checked on every two hours, however the investigation did not provide sufficient evidence to show R1 was checked on every two hours on the night of October 26, 2019. Based on the Departments investigation there is corroborating evidence to support the allegation that R1 sustained multiple injuries due to neglect, therefore this allegation is substantiated. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted and a copy of this report, along with LIC9099D and appeal rights were provided to Sheila Fike.the state’s words, verbatim · CDSS document, Sep 30, 2021 · control 18-AS-20191104153922

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Oct 8, 2021

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not being met as evidenced by: Based on interviews and record reviews, between January 1, 2019 and October 26, 2019, R1 sustained multiple falls. Licensee did not ensure staff had been sufficiently informed of R1’s fall risk and/or what precautions were to be used to mitigate further falls. This posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Executive Director will ensure staff are provided training on observation of residents and ensure their needs are being met. Proof of training will be submitted by 10/8/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 8, 2021

Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not being met as evidenced by: On October 26, 2019 R1 was observed with a bloody face and injuries to eye and lip. Staff interviews could not provide evidence as to how R1 sustained the injuries. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Executive Director will ensure staff are trained on expectations relating to their knowledge of residents care plan to ensure their needs are met. Proof of training will be submitted by 10/8/21.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced case management visit. LPA met with Sheila Fike, Executive Director. The purpose of the visit was to follow up on information obtained during the Department’s investigation of complaint control # 18-AS-20191104153922. On 10/26/2019, resident 1 (R1) was found sitting near the nurse station at approximately 0600. R1 had injuries to the face,eye and lip. R1 was provided first aid treatment, however, 911 was not called for approximately 1 hour 45 minutes after first being observed with injuries. A review of R1s medical records revealed R1 sustained a superficial laceration of the lip with minimal swelling, multiple superficial skin tears in the lower extremities, multiple bruises, closed head contusion, closed fracture of multiple ribs of rights side, initial encounter and hemopneumothorax on right side. Based on information obtained, the Department has concluded that staff failed to obtain emergency medical treatment for R1 in a timely manner. In accordance with California Code of Regulations, Title 22, Chapter 6 a citation is being issued as detailed on the attached LIC 809D. An exit interview was conducted and a copy of this report, along with appeal rights, were reviewed with and provided to Sheila Fike.the state’s words, verbatim · CDSS document, Sep 30, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Oct 8, 2021

Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not being met as evidenced by: R1 was first observed at approximately 0600 with injuries to the face, eye and lip. Staff failed to call 911 for emergency medical treatment until approximately 0745. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Sep 30, 2021

Plan of correction: Executive Director will ensure staff are provided training of when to contact 911 and seek medical attention for residents. Proof of correction will be submitted by 10/8/21.

Allegation investigated: Resident not allowed visitations. Resident not allowed incoming or outgoing phone calls. Resident is not given telephone privacy. Staff not allowing resident to speak with Ombudsman. Resident is not provided a proper bed. Facility staff is not providing adequate activities for the resident(s)

On 8/4/21 Licensing Program Analysts (LPA)s Shaunte Henry and Anna Bueno conducted an unannounced visit for the purpose of delivering the findings to the above allegations. The LPAs met Fanny Villalobos explained the nature of the visit and were granted entry. LPA Henry spoke to Executive Director Heather Myers via phone. An interview with Resident 1's (R1)s Power of Attorney revealed that R1 is allowed visitation; is allowed incoming and outgoing calls; is given telephone privacy; is allowed to speak to an Ombudsman; has a proper bed; and has access to adequate activities. An interview with R1 confirmed that all 6 allegations are false. The ED denied all 6 allegations. This agency has investigated the complaint allegation. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted where this report was provided to Fanny Villalobos. Unfoundedthe state’s words, verbatim · CDSS document, Aug 4, 2021 · control 18-AS-20210413091720

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Shaunte Henry and Anna Bueno arrived at the facility to conduct an unannounced annual inspection with an emphasis on infection control. A risk assessment was conducted at the front desk where staff confirmed there are no Covid 19 cases in the facility. LPA met with health services manager, Fanny Villalobos, explained the nature of the inspection and was granted entry into the facility. LPA's were screened for temperature and COVID-19 symptoms. LPA toured the facility with the health service manager. There is a mitigation plan in place to help mitigate the spread of COVID-19 in the facility. There is one point of entry for routine COVID-19 symptoms screening is initiated for all residents, staff and visitors. Signs have been posted throughout the facility which indicates the visitor policy and proper hand washing, cough/sneeze etiquette, and social distancing practices. LPA observed hand sanitizer throughout the facility. All residents have at least a 30-day supply of medications. LPAs observed a sufficient supply of hand hygiene, cleaning and disinfecting items. LPAs observed a sufficient supply of Personal Protective Equipment (PPE) that included surgical masks, N-95 masks, face shields, gloves, gowns, glasses, etc. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. The facility has a COVID mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning/sanitizing/disinfecting and monitoring of individuals for COVID-like symptoms. The facility is aware that it is mandatory that CCL is contacted if anyone tests positive for COVID-19. According to California Code of Regulations, Title 22, Division 6, there were no deficiencies observed or cited during this visit. An exit interview was conducted where this report was discussed with and provided to the health services manager.the state’s words, verbatim · CDSS document, Aug 4, 2021