California Sunshine RCFE

Type of visit: Required - 1 Year

On 4/14/2023 at 12:30 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Crystal Vaka and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory. LPA toured facility with Crystal including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. LPA observed locked gate around pool. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 108.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was purchased on 9/25/2022. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 03/22/20223. Report continues on 809 C. At 12:45 PM LPA reviewed 4 residents records. At 1:10 PM LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. At 2:40 PM, LPA reviewed a sample of 3 resident’s medications. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: -At approximately 1:06 PM LPA observed resident files were incomplete. Resident 1 R1), R2 and R3 files are missing LIC 601, and LIC 603A. LPA observed R4 file to be empty, Administrator stated that their file was still at their previous facility and has not been brought to this facility. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided..the state’s words, verbatim · CDSS document, Apr 14, 2023

Type of visit: Required - 1 Year

On 12/08/2022 at 9:35 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Caregiver, Maupuka and explained the purpose of the visit. LPA spoke with Administrator, Crystal Vaka, on the phone. Administrator joined the visit approximately an hour later. During the Infection Control Inspection, LPA toured facility with Maupuka and Crystal including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient two day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. A sign-in policy, hand sanitizer, and thermometer were observed at screening station. Social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30 day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. Fire extinguisher was observed serviced. LPA observed facility passages inside and out free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 8, 2022

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 an unexplained injury Facility failed to seek resident medical attention for a fall Resident has sustained several falls while in care Facility failed to report resident's fall Resident's room has feces on the wall

On 04/21/22 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with staff (S2) and administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with staff (S2) and spoke with administrator on the phone who authorized S2 to act on her behalf and sign the reports. Allegation: Resident sustained an unexplained injury Investigation Finding: SUBSTANTIATED Based on interviews and record reviews, staff (S1) gave neutral witness (W1) 3 different versions of what happened to resident (R1) on 11/06/2020. S1 told W1 that R1 fell from his chair. The second version was that R1 fell from his walker. The 3rd version was that staff (S1 & S2) saw R1 on the floor when they entered his room. S1 told W1 that they gave R1 an ice pack and polysporin for his forehead lump. The preponderance of evidence has been met. Therefore, this allegation is substantiated. Continued on next page, LIC 9099-C Substantiated Allegation: Facility failed to seek resident medical attention for fall Investigation Finding: SUBSTANTIATED Based on interviews and record reviews, staff failed to seek resident (R1) medical attention for fall (11/07/20). Administrator stated R1 has loose urination and tended to urinate on the floor instead of his commode. R1 tripped on his walker and fell on his face due to the wet floor. R1’s black eye and lump above his left eyebrow did not show until after 2 days. Neutral witness (W1) confirmed staff did not seek medical attention for R1 when fall incident occurred. The preponderance of evidence has been met. Therefore, this allegation is substantiated. Allegation: Resident has sustained several falls while in care Investigation Finding: SUBSTANTIATED Based on interviews and record reviews, staff (S1) confirmed with LPA that resident had several falls which he logged on the computer (9/13/20, 9/23/20, 10/18/20, 10/19/20 and 11/07/20. The preponderance of evidence has been met. Therefore, this allegation is substantiated. Allegation: Resident’s room has feces on the wall Investigation Finding: SUBSTANTIATED Based on interviews and record reviews, staff (S1) confirmed with LPA that he cleaned R1’s alleged fecal matter smeared on R1’s wall on11/06/20 as instructed by neutral witness (W1) who visited facility unannounced on official business. The preponderance of evidence has been met. Therefore, this allegation is substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Apr 21, 2022 · control 15-AS-20201109145516

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 20, 2022

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (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 was not met as evidenced by resident sustaining unexplained injury which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on residents’ personal rights as specified under Title 22 regulation Section 87468.2. Administrator will submit to CCLD copy of completed staff retraining.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(1) · Plan of correction due date: May 20, 2022

The plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes This requirement was not met as evidenced by staff failing to seek medical attention for resident's fall which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: By POC due date, administrator agrees to conduct in-service staff retraining on timely addressing residents’ medical needs. Administrator agrees to submit completed staff retraining certifications to CCLD

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(2) · Plan of correction due date: May 20, 2022

The plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met as evidenced by resident sustaining several falls which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper supervision and care of residents. Administrator will submit to CCLD copy of completed staff retraining.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 20, 2022

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement was not met as evidenced by staff not reporting incidents to the licensing office which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on reporting requirements as specified under Title 22 regulation Section 87211. Administrator will submit to CCLD copy of completed staff retraining.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 20, 2022

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by fecal smears on resident's wall which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on residents’ personal rights as specified under Title 22 regulation Section 87468.1. Administrator will submit to CCLD copy of completed staff retraining .

Allegation investigated: Staff is not allowing resident the option of choosing their preferred hospice agency provider.

On 04/21/22 at 10:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with staff (S2) and administrator (ADM) to deliver the finding of above allegation. LPA explained the purpose of the visit with S2 and spoke to administrator on the phone who authorized S2 to act on her behalf and sign the reports.. Allegation: Staff is not allowing resident the option of choosing their preferred hospice agency provider. Investigation Finding: UNSUBSTANTIATED Based on interviews and record reviews, staff (ADM) stated each resident who is ordered by his/her doctor to be under hospice care chooses their own hospice agency provider. Continued on next page, LIC 9099-C Unsubstantiated Facility staff does not dictate or force any resident to use a specific hospice care agency. They do not have a specific hospice agency that they use. The issue with resident (R1) was that her authorized representative and family refused to communicate R1's hospice care plan with staff because they did not want to pay the additional $50 per day for hospice care as specified in their admission agreement. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Apr 21, 2022 · control 15-AS-20211207092953