C.A.L.L.-Carmelita House

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at facility for an unannounced annual inspection visit. LPA met with Administrator Brenda Victoria and explained the purpose of the visit. LPA toured the inside and outside of the facility with Administrator the following was noted: Infection Control: The facility has an infection control plan on file. The facility is clean, safe and sanitary. The facility trains staff initially upon hiring and annually thereafter on infection control and PPE. The facility has about a 30-day supply of PPE on hand. The facility has a book to sign in an out for visitors at the facility and hand sanitizer is present. Operational Requirements: The facility is in compliance with the granted fire clearance. The facility is licensed for a capacity of 6, 5 of which can be non-ambulatory residents. The facility has an approved hospice waiver for 5. Physical Plant & Environmental Safety: The facility is a 5 bedroom and 2 bathroom home currently occupying 6 residents. The facility has smoke detectors and 1 carbon monoxide monitor. The lighting and lamps in resident rooms are sufficient for the use of the facility and for resident’s comfort. The facility kitchen is clean, safe, and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are locked in laundry room and under the kitchen sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. The facility has fencing around the back yard with a self closing and self latching gate. Continued 809-C Staffing: The facility has 11 staff and 1 administrator. Five staff files were reviewed for Health screening with TB results, Applications, fingerprint clearances, and First Aid and CPR certificates, all forms were legible and up to date. Personnel Records and Staff Training: The facility keeps staff files confidentially in the locked staff office. The facility administrator certificate expires on 03/20/2026. Five staff files were reviewed for initial and annual training requirements some staff are not meeting the hours or the subject matter requirements. Residents Rights/Information: Required postings were posted in the common area of the facility, Personal Rights, Persons with disabilities, CCL Complaint poster, License, rights to resident/family councils, Non-Discrimination notice, and visiting policy hours. Internet is provided to each client and each client is given confidentiality and privacy. Planned Activities: Four of the residents attend Day programs. The facility offers games, puzzles, arts and crafts, discussions, magazines, outings and walking. Food Service: The facility provides 3 meals and snack daily to all residents. The facility uses a posted menu for meals. The facility has two refrigerators and one separate freezer. The temperatures are kept within regulations requirements. Residents have likes and dislikes and meals are created around that. The facility has 2 days of perishables and 7 days of non-perishables. The facility has an emergency supply of food and water. Incidental Medical and Dental: The facility provide transportation to mecdial and dental appointments for all residents in care. The facility centrally stores medication in a locked cabinet in the medication room. All 6 residents medication was reviewed, no labels were altered, no medications were expired, and medications are being stored in their original containers. Resident Records/Incident reports: The facility has confidential binders for residents records stored in a locked staff office. The facility sends incident reports to the department when required. Five resident files were reviewed for signed Admission Agreements, ID/Emergency information, Consent forms, Medical Assessments, Appraisal Needs and services plans are done on the IPP's, and Safeguard for Property and Valuables. The facility does have the safeguard for cash resources and P&I monies were checked with ledgers, receipts and cash. Disaster Preparedness: The facility has the current disaster forms posted. The forms are legible and complete. The facility conducts quarterly disaster drills changing the type of disasters on each training. The facility has the supplies listed in the disaster plan with food and water. Continued 809-C Residents with special health conditions: The facility does accept dementia residents in care. Sharps, knives, cleaning products are kept locked and made inaccessible to residents in care. The facility does not currently have any residents on hospice, home health services, or using oxygen. If they do have residents on services those plans with be kept up to date. The facility is not using any exiting doors alarms. The facility has video surveillance in the common areas. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Oct 17, 2025

The state marks this report as 11 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not get timely medical care for resident

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Isabel Lopez, Supervisor and explained the purpose of the visit. LPA De Leon conducted the 10 - day complaint visit on 01/21/2025 collected records and conducted interviews with Staff at 1:30pm, 2:30pm, and 2:45pm. LPA De Leon conducted additional staff interviews on 01/28/2025 at 1:31pm, 2:20pm, 2:57pm and 3:59pm. On the allegation: Staff did not get timely medical care for resident LPA interview staff and resident charting records which revealed staff informed the lead/supervisor that resident 1 (R1) was having discharge and odor regularly. Charting notes have staff charting that R1 was having discharge and odor in 2024. R1 had a recent visit to CHC doctor on 01/15/2025 at 3:30pm which revealed R1 was prescribed antibiotics. Based on the evidence R1 did not receive timely medical care therefore the allegation is Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Supervisor. Substantiatedthe state’s words, verbatim · CDSS document, Jan 29, 2025 · control 29-AS-20250117160843

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Jan 31, 2025

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16)To receive or reject medical care or other services. This requirement was not met as evidenced by: Based on staff interviews and charting records the Licensee did not comply with the regulation above R1 was having discharge and odor in 2024 but R1 was not taken to see a doctor till 2025 which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee agreed to, review charting notes from staff daily and make appointments immediately for residents when they need them, provide a statement of understanding to CCL as well as review and train all staff on 87468.1 and 87468.2 Personal Rights regulations and provide proof of training with an up to date LIC 500 for staffing to CCL

Allegation investigated: Facility staff did not provide resident medical records to emergency personnel Licensee does not ensure staff are adequately trained to provide care for residents

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Isabel Lopez, supervisor and explained the purpose of the visit. LPA De Leon conducted the 10 - day complaint visit on 01/21/2025 collected records and conducted interviews with Staff at 1:30pm, 2:30pm, and 2:45pm. LPA De Leon conducted additional staff interviews on 01/28/2025 at 1:31pm, 2:20pm, 2:57pm and 3:59pm. On the allegation: Facility staff did not provide resident medical records to emergency personnel. LPA conducted interviews with staff that revealed staff working could not find the records the 911 EMT was requesting. The staff were able to retrieve and provide a few of the records. LPA reviewed the records at the facility and the records were not organized and most of the 2024-year records were not located. LPA was not able to locate some of the resident records required for emergency purposes. The facility recently put a staff in charge to clean up the records and filing at the facility. Based on the evidence the allegation is Substantiated at this time. Continued 9099-C Substantiated On the allegation: Licensee does not ensure staff are adequately trained to provide care for residents. LPA conducted interviews with staff and reviewed training records which revealed most staff felt they were trained although some felt hands on and 1 on 1 care of residents at the facility could be better. Training records revealed the facility has done more training in 2024 but not all staff did not take the required initial or annual training requirements. According to Tri- Counties Regional Center Quality Assurance the C.A.L.L. Program is not in compliance with keeping better track of all training's, data collection and charting notes. Based on the evidence the allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Supervisor. R1 was sent out to the hospital on a 911 call, was admitted to the hospital and discharged to a skilled nursing facility. R1 wounds were staged at a healing 2 when R1 was discharged back to the facility. According to medical records and interviews R1 never had stage 3 or 4 pressure injuries which is a prohibited health condition in CCL facilities. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report printed for Supervisor.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 29-AS-20250113160511

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.695(e)(1-4) · Plan of correction due date: Jan 31, 2025

(e)...:(1) A resident roster with the date of birth for each resident.(2) An ANS plan for each resident.(3) A resident medication list for residents with centrally stored medications.(4) Contact information for the responsible party and physician for each resident. This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the regulation above, staff were unable to locate the records for Resident to provide the EMT’s on a 911 call, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee agreed to review the facility emergency disaster plan LIC. 610E, health & safety code 1569.695, make sure facility is meeting this requirement with all records and supplies necessary and train all staff at the facility on the plan/code and provide proof of training with an up to date LIC. 500 to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Feb 5, 2025

(c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above staff were not properly training meeting all initial and annual training requirement which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee agreed to arrange all staff to take and met the required initial and annual training requirements for CCL and provide proof of each staff meeting the training requirements as well as an updated LIC 500.

Allegation investigated: Staff are not meeting resident's dental needs.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Isabel Lopez, supervisor and explained the purpose of the visit. LPA De Leon conducted the 10 - day complaint visit on 08/06/2024 toured the facility kitchen, collected records, and conducted interviews with Staff. LPA interviewed additional staff on 01/21/2025 at 1:30pm, 2:30pm, and 2:45pm. LPA De Leon conducted additional staff interviews on 01/28/2025 at 1:31pm, 2:20pm, 2:57pm and 3:59pm. On the allegation: Staff are not meeting resident's dental needs. LPA interviewed staff and reviewed charting and dental records for resident 1 (R1) which revealed R1 had charting notes and staff told lead/supervisors about R1’s loose teeth and bleeding, at some point the Lead/supervisor made a dentist appointment for R1 and R1 had oral surgery. Continued 9099-C Substantiated R1 was not compliant with the post care for the dental surgery and ended up in the hospital for further medical care. According to interviews R1 had been visited by onsite mobile dentist arranged through Tri-counties Regional Center in the 2024 on a few occasions. Staff interviews revealed staff wash assisting R1 with normal brushing and cleaning of R1 mouth and teeth. The lack of immediate attention to R1’s loose teeth and the reports staffing made to the lead/supervisor after the dental surgery were not immediate for R1’s needed care based on R1 not being seen timely this allegation is Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Supervisor. Staff would give several options of food and meals to R1, R1 would throw food R1 did not want to eat and would only eat what R1 wanted to eat. R1 ate cereal, yogurt and ensure drinks if R1 liked the flavor given. R1 did not like healthy food options given and would always eat the same things. R1 has a right to eat what R1 wanted but staff always offered several choices to R1. The facility had a menu they followed for meals to residents and always had additional choices if the resident did not like what was on the menu. Based on the evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report printed for supervisor.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 29-AS-20240730171129

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jan 31, 2025

(a) plan for incidental medical and dental care shall be developed by each facility. The...:(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on staff interviews and records review the Licensee did not comply with the regulation above, R1 had immediate dental needs that were not addressed timely by the lead/supervisor based on staff charting notes and verbal notifications which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee agreed to review regulation 87465 and have a full understanding of when to seek medical and dental care for residents, for lead staff to know full duty statement and sign a statement of understanding of how and when to seek medical and dental care for residents in care as well as train all facility staff on the regulation and reporting to lead staff at the facility, send proof of training and statement of understanding to CCL.

Allegation investigated: Licensee does not ensure the administrator is on the premises for a sufficient number of hours to manage the facility Staff do not ensure residents are taken to medical and dental appointments

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Isabel Lopez, Supervisor and explained the purpose of the visit. LPA De Leon conducted the 10-day complaint visit on 01/26/2024 and collect records. LPA conducted interviews with Staff on 01/22/2025 at 1:30pm, 2:30pm, and 2:45pm. LPA De Leon conducted additional staff interviews on 01/28/2025 at 1:31pm, 2:20pm, 2:57pm and 3:59pm. LPA asked to review R1 and R2's charting records for 2024 upon arrival to the facility today. On the allegation: Licensee does not ensure the administrator is on the premises for a sufficient number of hours to manage the facility. LPA conducted staff interviews and reviewed facility schedules and records which revealed the administrator on record was not the administrator at the facility. Continued 9099-C Substantiated The facility had high turn over and was not staffed with a lead/supervisor or Administrator several times throughout 2024. The Administrator on record did check in at the facility but did not have set schedule to spend time at the facility on a regular bases. The Administrators are assigned to homes to meet the administrator requirement but do not work at some of the homes regularly to oversee the business operation. The lead/Supervisor position is the staff that is scheduled at the home regularly but during the 2024 year this position had high turnover and staff was not in this home regularly to oversee the staff, residents, and business operation. Due to not having Administrator or lead/supervisor the facility was not getting the job duties of these position done creating staff to have to notify them of residents needs and not getting timely attention of those residents needs. The medical records and paperwork were not getting completed which led to staff not having important paperwork and records when needed. Based on the evidence this allegation is Substantiated at this time. On the allegation: Staff do not ensure residents are taken to medical and dental appointments. LPA interviewed staff and reviewed resident’s records which revealed staff did notify leads/supervisors/administrator of the need for medical and dental appointments for residents in care. Due to high turned over and not having the staff available to arrange these appointments timely so appointments did not get made timely, some appointments were made but several months out which did not address the needs of the residents timely and some appointments had to be rescheduled. The staff did not follow up on medical and dental issues in a timely matter for some of the residents in care. Based on the evidence this allegation is Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Supervisor.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 29-AS-20240119110310

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Feb 5, 2025

(a)All facilities shall have a qualified and currently certified administrator....shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...This requirement was not met as evidenced by: Based on staff interview and record review the Licensee did not comply with the regulations above, Administrators or back up were not on the premises, to permit adequate attention to the management or administration of the facility operations which possess a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee agreed to review and have a statement of understanding in Regulation 87405 and train all staff in the regulation requirements and provide proof of training and an updated LIC 500 to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Feb 5, 2025

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16)To receive or reject medical care or other services. This requirement was not met as evidenced by Based on staff interviews and charting records the Licensee did not comply with the regulation above Resident were not taken to see a doctor/dentist in a timely matter when medical/dental service were needed which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee agreed to, review charting notes from staff daily and make appointments immediately for residents when they need them, provide a statement of understanding to CCL as well as review and train all staff on 87468.1 and 87468.2 Personal Rights regulations. Provide proof of training with an up-to-date LIC 500 for staffing to CCL.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) De Leon conducted a complaint visit and opened a case management visit due to deficiencies found during the visit. LPA met with staff whom called House Supervisor in Training and Call Program Supervisor Regina Ceasar. Upon arrival of each supervisor LPA explained the purpose of the visit. LPA requested the following records at 10:45am for the complaint visit and did not received those records until around 2:30pm. LPA was provided R1 and R2's records in large binders, LPA reviewed binders and LPA had to pull the records needed for copies to be made by facility. Facility provided requested records at 2:30pm. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for CALL Supervisor.the state’s words, verbatim · CDSS document, Jan 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d) · Plan of correction due date: Jan 28, 2025

(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying....: This requirement was not met as evidenced by: Based on record review the licensee did not comply with the regulation above, records were not provided to LPA, LPA had to look for records requested, copies of records took over 3 hours to be provided which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2025

Plan of correction: Licensee agreed tol train all staff in regulation 87506, provide proof of training with an up to date LIC 500 Personnel Report for the facility.

Allegation investigated: Staff do not accord dignity to resident(s) in care.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Joni Chapman and explained the purpose of the visit. During the initial visit on 8/18/2023 from 10:10am to 12:05pm, LPA Chavez toured the facility, interviewed staff, and obtained relevant documents. On 9/7/2023 at 9:02am, LPA interviewed Executive Director (ED) regarding video footage in the facility. ED stated they reviewed footage for dates 8/3/2023 through 8/9/2023, and the system did not go back further. On the allegation: Staff do not accord dignity to resident(s) in care. It was alleged a staff (Staff 1 – S1) spoke inappropriately to clients. On 6/17/2023, S1 allegedly told Client 1 (C1) “I don’t give a f---” and “shut the f--- up.” It was also alleged S1 yells at clients and makes them feel bad if they have incontinence episodes. Substantiated Administrator stated a different on-call staff “had a bit of attitude,” and was “short” with clients and not the most patient. However, this staff never “lashed out” at clients. Another staff stated one staff is “sometimes pushy and firm but cares for clients.” Administrator stated there was one instance where a staff was sitting at the kitchen counter and C1 was telling a story, and the staff just walked away and did not listen to C1. Administrator stated S2 was not caring about the quality of care and was let go due to performance issues. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.the state’s words, verbatim · CDSS document, Oct 29, 2024 · control 29-AS-20230814164102

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 12, 2024

87468.1(a)(1) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff... This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 yelled at residents in care, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Facility will ensure all staff attend a training focused on Resident Personal Rights. Facility will provide CCL with copy of training agenda as well as a sign in sheet for all staff who attended the training.

Allegation investigated: Staff did not respond to resident’s requests for assistance. Staff are handling resident(s) in a rough manner while in care. Facility did not report alleged abuse.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Joni Chapman and explained the purpose of the visit. During the initial visit on 8/18/2023 from 10:10am to 12:05pm, LPA Chavez toured the facility, interviewed staff, and obtained relevant documents. On 9/7/2023 at 9:02am, LPA interviewed Executive Director (ED) regarding video footage in the facility. ED stated they reviewed footage for dates 8/3/2023 through 8/9/2023, and the system did not go back further. On the allegation: Staff did not respond to resident’s requests for assistance. It was alleged on 7/5/2023, Client 2 (C2) was in bed and asked S1 for water, but S1 did not provide C2 with water and laughed. It was alleged S1 regularly denies things clients ask for and ignore them when they request assistance. Continued on 9099-C Unsubstantiated Administrator stated they had not heard about a staff refusing water to a resident, and stated staff never refuse water. Administrator noted one resident always like to drink water, and they place bottled water in resident’s rooms. Staff interviewed stated they had not observed staff refuse water to any clients, and stated “we give clients what they ask for.” Clients in the home were interviewed, and were unable to provide feedback on their care. LPA interviewed a credible witness, who stated at the time of this complaint they had not heard of staff not providing clients water. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. On the allegation: Staff are handling resident(s) in a rough manner while in care. It was alleged on 7/30/2023, S1 bragged about dragging C1 out of another client’s room by their feet, from a distance from the bed to the doorway. Allegedly, S1 stated no matter what they do, the facility will not fire them. A credible witness also spoke with staff, who indicated C1 sometimes needs assistance leaving other client’s rooms, but is compliant when escorted out by staff. All staff denied rough handling to the credible witness. ED stated they reviewed video footage in the facility for dates 8/3/2023 through 8/9/2023, and did not observe anything concerning and no indications on the video footage C1 was dragged. However, ED observed footage that another client (C3) tripped on 8/30/2023, put their hand out on a door jamb, and dislocated their finger, even though staff were right behind C3. Staff interviewed stated they had never witnessed staff pulling a client or handling a client in a rough manner. Staff stated if that were to happen, they would report it to a lead or supervisor, and create documentation or an incident report. Clients in the home were interviewed, and were unable to provide feedback on their care. LPA interviewed a credible witness, who stated at the time of this complaint they had not heard of staff handling residents in a rough manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Continued on 9099-C On the allegation: Facility did not report alleged abuse. It was alleged the behaviors of S1 were reported to facility Human Resources (HR) and management, but the alleged abuse was not reported. Administrator stated they were not aware of any abuse in the facility, and do not believe any rough handling occurred. Administrator stated staff would report the abuse. Staff interviewed stated they had never witnessed staff pulling a client or handling a client in a rough manner. Staff stated if that were to happen, they would report it to a lead or supervisor, and create documentation or an incident report. Administrator stated S2 was not caring about the quality of care and they were let go after another staff reported the performance issues. On this complaint, there was insufficient evidence to substantiate that abuse occurred, and therefore insufficient evidence to prove it was not reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Exit interview, report given.the state’s words, verbatim · CDSS document, Oct 29, 2024 · control 29-AS-20230814164102

Allegation investigated: Staff hit, and or pushed and or yelled at residents in care. Resident fell due to staff not assisting resident appropriately.

Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Joni Chapman and explained the purpose of the visit. During the initial visit on 1/4/2024 from 2:00pm to 5:10pm, LPA De Leon toured the facility and interviewed staff and residents, and obtained relevant documents. On the allegation: Staff hit, and or pushed and or yelled at residents in care. It was alleged Staff 1 (S1) tells residents to shut up, hit Resident 1 (R1)’s hand, and yelled at R1. It was also alleged S1 was abusive to R1 in the shower by pushing them. Multiple staff interviewed stated they have heard S1 yell at residents, particularly R1 and R2. One staff stated S1 tells residents to shut up. Staff confirmed the bathroom incident occurred where S1 yelled at R2 in the shower. Substantiated Multiple staff interviewed stated they have observed S1 slamming cupboards, which was disruptive to residents. Staff also stated S1 has argued with them in front of clients, after refusing to help with tasks that would assist clients, such as retrieving yogurt for a resident that had a cough. One Agency staff, a Certified Nursing Assistant (CNA), interviewed stated they had not witnessed either incident, and had not seen or heard S1 yell, hit or scream at a resident, but had heard of things happening from other staff. Multiple staff stated S1 gets rude and defensive when other staff intervene and inform S1 their behavior is inappropriate. Multiple staff stated they informed the supervisor after witnessing the incidents and inappropriate behavior from S1. Staff asked the manager if S1 could cover different clients in the facility that are more independent than the ones S1 was currently assisting, and this was enacted. Staff stated R1 and R2 get very agitated when S1 is on shift following the incidents. On the allegation: Resident fell due to staff not assisting resident appropriately. It was alleged when assisting Resident 2 (R2) at the dining table, S1 did not properly assist R2 and allowed R2 to fall, when the fall could have been prevented. One staff stated they were a witness to the fall incident on 12/26/2023 with S1 and R2. R2 uses a walker, and staff interviewed stated they need to make sure the chair is stable before R2 sits down. S1 was in charge of care for R2 and was getting R2 to the dining table. R2 typically sits in a chair at the dining table, but on this occasion, S1 had R2 stand up holding onto the table and repositioned R2’s walker backwards to sit on. R2 lost their balance and started to stumble, and other staff present believed S1 could have prevented the fall from occurring by assisting R2 to slide down instead of fall, but S1 backed away and instead let R2 fall. Another agency staff, a Certified Nursing Assistant (CNA), on duty went over to assist, and S1 tried to sit R2 on the walker again. The CNA instructed S1 to get a real chair for R2. Another staff went to assess R2 after the fall to ensure they were walking ok. R2 was not hurt in this incident. Staff stated after this incident, S1 does not work with R2 due to being “neglectful in [their] duties.” The Administrator at the time confirmed these two separate incidents with S1 occurred, on different days. The shower incident occurred around 12/10/2023-12/15/2023 and the fall incident with R1 occurred on 12/26/23. There is camera footage of the chair incident but not the bathroom incident. Administrator stated at first they thought there was not enough evidence to prove the bathroom incident occurred, until another staff stated they witnessed the incident. Then they reported the incident to Corporate. Administrator stated they counseled S1 on 12/28/2023 about their behavior. Supervisor stated S1 was not being left alone with residents and other staff were present supervising after the incident. Administrator and supervisor stated S1 was a new staff and had been written up multiple times. The first write-up was on 12/15/2023 for yelling at R2 in the shower and arguing with another staff loudly in the presence of residents. S1 also received a write-up for the chair incident. Based on the information obtained, both allegations are deemed Substantiated at this time. Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.the state’s words, verbatim · CDSS document, Oct 29, 2024 · control 29-AS-20231229115806

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 30, 2024

87468.2(a)(4) Personal Rights. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 deviated from protocol and had R2 sit on theirthe state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Facility will ensure all staff attend a training focused on Resident Personal Rights. Facility will provide CCL with copy of training agenda as well as a sign in sheet for all staff who attended the training. walker, resulting in a fall, which posed an immediate safety risk to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 30, 2024

87468.1(a)(1) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff,... This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 yelled at residents in care, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Facility will ensure all staff attend a training focused on Resident Personal Rights. Facility will provide CCL with copy of training agenda as well as a sign in sheet for all staff who attended the training.

Type of visit: Required - 1 Year

At 9:00 am on 10/29/2024, Licensing Program Analyst (LPA) Rankin arrived at facility for an unannounced annual inspection visit. LPA met with Administrator Joni Chapman. During inspection tour of the facility was conducted and records reviewed. Personnel Records: The facility employes 9 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files for 1st AID/CPR, Fingerprint clearances, Applications, Health exam with TB results, and Criminal Record statement. All required records were reviewed, one staff will be attending 1st Aid/CPR training before returning to the schedule. Physical Plant & Environmental Safety: The facility is a 5 bedroom and 2-bathroom home currently occupying 6 residents. The facility has dual smoke and carbon monoxide detectors. The lighting and lamps in resident rooms are sufficient for the use of the facility and for resident’s comfort. The facility kitchen is clean, safe, and sanitary. The showers have non-skid flooring. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are locked in laundry room and bathroom cupboards. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Clients Rights – Required postings were posted in the common area of the facility, Personal rights and Persons with disabilities as well as the CCL Complaint poster, Ombudsman poster will be requested for posting. The current license along with disaster plan was posted. Internet is provided to each client and each client is given confidentiality and privacy. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin, and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Disaster Preparedness: The current emergency disaster forms were posted, due to recent change in administrator, updates are being done and will be reviewed during final annual visit. The fire extinguishers were charged. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. LPA will return at a later date to complete annual review. Copy of report given to administrator.the state’s words, verbatim · CDSS document, Oct 29, 2024

Allegation investigated: Facility staff are not qualified. Facility does not have an administrator. Facility staff are not ensuring that residents attend their appointments.

On 10/23/2023 at 9:00am, Licensing Program Analyst (LPA) Jeffries conducted an unannounced follow-up visit to deliver final findings on the original complaint dated 6/22/2023. LPA met with Intin Adminstrator Valerie Braisher-King and explained the purpose of the visit. On the allegations, “Facility staff are not qualified” and “Facility does not have an administrator,” the complainant’s concern was that the facility’s administrator left on 6/20/2023 and there was no replacement or backup lead staff in place. LPA interviewed staff who indicated the licensee’s president was at the facility on 6/20/2023 and the Office Manager was at the facility on 6/21/2023 to help with medications. During LPA Chavez visit on 6/23/2023, LPA Chavez notified the facility they would need a replacement administrator, and the Office Manager indicated they were preparing the paperwork for another administrator to take over. LPA Chavez received the paperwork and updated the administrator on record. CONTINUED on LIC9099-C Unsubstantiated The facility also had two other administrators of the licensee’s other facilities designated as on-call administrators. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. On the allegation, “Facility staff are not ensuring that residents attend to their appointments,” the complainant’s concern was that because there was no administrator, the residents missed appointments. LPA Chavez interviewed Office Manager on 6/23/23. Office manager showed LPA Chavez a desk calendar with appointments. The calendar showed Resident 1 (R1) has an appointment on 6/28/23. The Office Manager stated she was trying to figure out where things were after the former administrator left on 6/20/23, and believed the appointments scheduled were on the desk calendar. However, no one was able to access the former administrator’s work cell phone, which could have appointments in it, but this was not confirmed. LPA Jeffries interviewed S6 who was working during the time of complaint, and confirmed no appointments were missed. LPA Jeffries could not find any documentation indicating appointments were missed. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview, report given.the state’s words, verbatim · CDSS document, Oct 23, 2023 · control 29-AS-20230622164857

Type of visit: Required - 1 Year

At 9:00am on 10/23/2023, Licensing Program Analyst (LPA) Mark Jeffries arrived at facility for an unannounced annual inspection visit. LPA met with Intern Administrator Valerie Braisher-King. LPA toured facility with Administrator. The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning throughout the facility. Fire extinguishers were fully charged. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 73 degrees F. Hot water temperature tested and read within regulation requirements. Residents’ rooms are appropriately furnished with adequate lighting, storage and bedding. LPA observed more than two days of perishable and more than seven days of non-perishable food. Food is stored in proper containers in the refrigerator and freezer. A written disaster and mass casualty plan is readily available located on the facility office. LPA reviewed medications and conducted a sample medication audit.. Medications are stored in a locked cabinet in the staff storage room. There is a signed and dated order from a physician for prescription and PRN medication. LPA observed the medication administration record (MAR) and medications are given per physician's orders. Intern Administrator and LPA conducted a full review of the annual care tools. There was one technical violation noted on documentation of quarterly fire drill. Intern Administrator to conduct drill today (10/23/2023) to maintain regulation compliance. No other technical, citation, or deficiencies were noted on the full annual care tools review. Exit interview, no deficiencies or citations issued, report given.the state’s words, verbatim · CDSS document, Oct 23, 2023

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.