C.A.L.L. - Valdez House

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:30 am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Kylan Reynoso and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. PPE and infection Control Training is done initially upon hire and annually thereafter. All sinks have soap, paper towels, hand washing signs. Physical Plant & Environment Safety: The facility is a 3 bedroom and 2 bathroom home currently occupying 3 residents with 1 bedroom being shared. The facility employs 9 staff and 1 administrator. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility is fully fenced around the backyard with a self closing and latching gate. The facility has a patio with furniture and awning for shade. Laundry room is in the garage and has a working washer and dryer, garage is kept locked with all laundry and cleaning supplies. Water was tested in bathroom #2 at 105.7F. Operational Requirements: The Facility is operating in compliance with granted fire clearance. The facility is cleared for 4 non-ambulatory with a Hospice wavier granted for 4. The facility liability insurance expires 09/01/2026. Staffing: The facility employes 9 staff and 1 Administrator. Staff records are kept confidential. Staff records were reviewed for 5 staff for fingerprint clearance and associations, personnel record or application, First Aid and CPR valid certificates, CPI valid training certificates and Health screening with TB results. Resident Rights Information: All require postings were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, Nondiscrimination notice in addition to a CCL Complaint poster and LTCO posted. Continued 809-C Personnel Records & Training: The facility keeps confidential files for each staff member. The facility is using Relias online system for 2025-2026 all staff have 20 plus hours of annual training completed. Administrator Certificate expires 12/03/2027. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Three Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS) or IPP, TB results, Personal Rights, and Safeguard for personal property and valuables. Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines, newspapers, TV watching, daily walks, group discussions, communications and gestures, with games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. The residents attend day programs during the day. 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. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available in the garage. Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 3 residents. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR) and the Medication Administration record (MAR). LPA completed a full audit on three residents medication, all medications were stored in original containers, prescription labels were not altered, medications were not expired, doctors orders were present and dispensing instructions were followed. Disaster Preparedness: The current emergency disaster forms were posted. The fire extinguishers were charged and last inspected 12/18/2025. The smoke detectors and carbon monoxide detectors are present. The facility does conduct disaster drills quarterly and records were present. Residents with Special Health Needs: The facility has submitted a updated plan of operation to accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards/drawers. The facility does not have delayed egress. The facility does not have any residents with oxygen. The facility does not currently have any residents with a dementia diagnosis, and no current residents on hospice or home health services. Exit interview conducted, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Jul 22, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:00 am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Kylan Reynoso and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan to CCL. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. PPE and infection Control Training is done initial upon hire and annually thereafter. All sinks have soap, paper towels, hand washing signs. Physical Plant & Environment Safety: The facility is a 3 bedroom and 2 bathroom home currently occupying 4 residents with 1 bedroom being shared. The facility employs 9 staff and 1 administrator. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility is fully fenced around the backyard with a self closing and latching gate. The facility has a patio with furniture and awning for shade. Laundry room is in the garage and has a working washer and dryer, kept locked with all laundry and cleaning supplies. Operational Requirements: The Facility is operating in compliance with granted fire clearance. The facility is cleared for 4 non-ambulatory with a Hospice wavier granted for 4. The facility liability insurance expires 09/01/2025. Continued 809-C Staffing: The facility employes 9 staff and 1 Administrator. Staff records are kept confidential. Staff records were reviewed for 5 staff for fingerprint clearance and associations, personnel record or application, First Aid and CPR certificates and Health screening with TB results. 3/5 Staff had missing records or files. Personnel Records & Training: The facility keeps confidential files for each staff member. The facility staff are not meeting the required hours and subjects for initial and annual training and are currently scheduled to take all required training's for 2025. Some staff had training records but the records did not met the amount of hours or the required topics. The facility is using Relias online system for 2025 but did not have the records present for the staff at the facility. Administrator Certificate expires 12/03/2025. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), Immunization records, TB results, Personal Rights, and Safeguard for personal property and valuables. The four files reviewed were lacking records and not complete at this time. Resident Rights Information: All require postings were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, Nondiscrimination notice in addition to a CCL Complaint poster. Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines, newspapers, TV watching, daily walks, group discussions and communications and gestures, with games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. The residents attend day programs during the day. 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. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available in the garage. Foods need to be wrapped and stored with lids. Continued 809-C Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 4 residents. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR) and the Medication Administration record. all were up to date, legible and written as prescribed. LPA completed a full audit on four residents medication, all medications were in original containers, prescription labels were not altered, doctors orders were present and dispensing instructions were followed. Disaster Preparedness: The current emergency disaster forms were posted. The fire extinguishers were charged and last inspected 12/18/2024. The smoke detectors and carbon monoxide detectors are present. The facility does conduct disaster drills at facility but records were not up to date for the last 4 quarters. Residents with Special Health Needs: The facility has submitted a updated plan of operation to accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility does not have delayed egress. The facility does not have any residents with oxygen. The facility does not currently have any residents on hospice and home health services. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Jul 18, 2025

The state marks this report as 43 pages; the online copy we transcribed has 11. You can request the full file from the county licensing office.

Allegation investigated: Facility staff speaks inappropriately to residents in care.

At 7:30am on 10/07/2024, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with Alternate Administrator, Randyn Torres and explained the purpose of the visit. During the investigation, LPA De Leon conducted an initial visit on 1/23/2024 from 10:00am to 2:08pm, where LPA interviewed staff and residents and requested documents. As to the allegation of, "Facility staff speaks inappropriately to residents in care." It was alleged clients are being inappropriately spoken to and not being treated with dignity and respect by Staff 3 (S3). Multiple staff interviewed stated they raise their voice and lose their patience with clients. Multiple staff stated they have heard S3 raise their voice in R1’s room and in the kitchen. Staff interviewed stated they have seen S3 “mock” R1 and mimic R1. Staff stated S3 has been “verbally and mentally abusive” and shows aggression to the residents. Staff stated they have heard S3 speak unkindly to the residents but they stop it and tell S3 they cannot talk like that. One staff stated they had three other staff make reports about S3’s behavior to them. CONTINUED on LIC9099-C Substantiated Some of these incidents included raising their voice in R1’s room, and being mean to R2 when asked if staff could hold their hand on a walk due to unsteadiness. Other staff confirmed they reported the issues through their chain of command. The staff reported these issues to the administrator. S3 also scolded R2 for taking keys, that R2 did not take. Staff noted R1 appeared to be “paranoid,” “skittish,” and “afraid” of S3, and wants to know where S3 is. Staff stated S3 also does not do things safely around client, such as turning the stove on and walking away from it. LPA reviewed a write-up dated 1/8/2024 for S3 that discussed how to talk and redirect clients with a positive attitude; choose words that are encouraging instead of demeaning; work on tone and vocab in redirecting; give client time; encourage all clients in the home with positivity. S3 had another write up dated 6/25/2023 that stated proper chain of command must be followed; gossip is not tolerated and needs to be reported to on-call supervisor or HR; clients rights and mandatory reporting; proper redirection/de-escalation CPI techniques. S3 had additional counseling/disciplinary notice for 2/25/2021 due to a medication error; 7/14/2019 due to hitting a pothole with the facility van, causing damage; and 8/15/2018 due to being tardy on multiple shifts. Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.the state’s words, verbatim · CDSS document, Oct 7, 2024 · control 29-AS-20240118165403

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 21, 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, residents, and other persons. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when residents were not treated with dignity, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2024

Plan of correction: POC: Administrator agrees to hold personal rights training with a Community Care Licensing certified vendor, with all staff by 10/21/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 11:30 am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Kylan Reynoso and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan to CCL. The facility has EPA approved disinfectants spray and cleaners. The facility has trash cans/bins with covers. The facility has a 30 day supply of PPE. PPE and infection Control Training is done annually. All sinks have soap, paper towels, hand washing signs. Physical Plant & Environment Safety: The facility is a 3 bedroom and 2 bathroom home currently occupying 3 residents and 8 staff, including one administrator. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility is fully fenced around the backyard with a self closing and latching gate. The facility has a patio with furniture and umbrella for shade. Laundry room has working washer and dryer. Operational Requirements: The Facility is operating in compliance with fire clearance. The facility is cleared for 4 non-ambulatory with a Hospice wavier granted for 4. The facility liability insurance expires 09/01/2024. Staffing: The facility employes 7 staff and 1 Administrator. Staff records are kept confidential. Staff records were reviewed for 5 staff. 3/5 Staff records reviewed had fingerprint clearance and associations, personnel record or application, First Aid and CPR certificates and Health screening with TB results. 7/8 staff had current first aid and cpr card verified. One staff will not work until it is renewed. 2/8 staff had current CPI cards. Personnel Records & Training: The facility keeps confidential files for each staff member. The facility staff are not meeting the required hours and subjects for initial and annual training and are currently scheduled to take all required training's for 2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), Immunization records, TB results, Personal Rights, and Safeguard for personal property and valuables. Files are in compliance. Resident Rights Information: All require postings were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, Nondiscrimination notice in addition to a CCL Complaint poster, and LTCO poster. Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines, newspapers, TV watching, daily walks, group discussions and communications and gestures, with games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. 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. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available in the garage. Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 3 residents with the Centrally Stored Medication and Destruct Records (CSMDR) all were up to date, legible and written as prescribed. LPA completed a full audit on three residents medication, all medications were in original containers, prescription labels were not altered, doctors orders were present and dispensing instructions were followed and not medications were expired. Disaster Preparedness: The current emergency disaster forms were posted. The facility 1 disaster drill for 2024, and 2 from 2023. and will add additional drills to their schedules. The fire extinguishers were charged and last inspected 12/2023. The smoke detectors are present. Facility is getting a new carbon monoxide detector. Residents with Special Health Needs: The facility has submitted a update plan of operation to accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility does not have delayed egress. The facility does not have any residents with oxygen. The facility does not have hospice and home health currently visiting any residents in care. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Jul 26, 2024

The state marks this report as 31 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff do not meet resident’s incontinence needs Facility staff do not ensure resident's hygiene needs are being met

Licensing Program Analyst (LPA) De Leon conducted a 10 day complaint visit to the facility above. LPA was greeted by staff that contacted Administrator. Administrator arrived to the facility to meet with LPA, LPA explained the purpose of the visit. LPA requested the following records: All four residents LIC 602A Physicians report, Resident 1 (R1) Appraisal Needs and Services Plan, R1's IPP/ISP/Behavioral plans from TCRC, any of R1's hospital discharge paperwork for April/May 2024, Resident Roster, Staff Roster, Staff Schedule for April/May 2024. LPA conducted interviews with Staff. Residents at the facility were unable to be interviewed. LPA reviewed R1's records at the facility. R1's records were up to date. R1's LIC 602A Physicians report is dated 08/01/2023, Supports Intensity Scale Adult Version profile information dated 11/20/2023 and 04/04/2024, Praise Behavioral Support Plan dated 04/04/2024, Individual Program Plan Agreement dated 05/01/2024, Individual Service Plan dated 05/01/2024, continued 9099-C Unsubstantiated Behavior Plan at a Glance dated 04/04/2024, Twin Cities Community Hospital Discharge dated 05/12/2024 and all forms were current. The facility is keeping up with all plans to provide R1 the best possible care with the refusal behaviors at this time. On the allegation: Facility staff do not meet resident’s incontinence needs. Based on interviews the staff at the facility do change R1 several times a day, use wipes to clean R1 and sponge bath R1 daily. The staff have not been able to get R1 to take a shower due to R1's refusals. The staff have tried different times of the day and different staff asking R1. R1 is only allowing a few staff to help R1 and it has been by wipes or sponge bathing. R1 used to use the restroom but R1 has been incontinent wearing briefs now since November of 2023. R1 had a recent 911 ER visit due to staff coming on shift worried about R1 and that R1's refusals may have lead to sores and or sepsis. R1's discharge from the ER did not have any notations in regards to neglect, sores or sepsis. The discharge diagnosis was Abdominal Pain with Diarrhea and a follow up appointment with Primary Care Physician (PCP) was requested. R1 has an appointment on June 6, 2024 at 2:15pm which was the soonest staff was able to get R1 in to see PCP. Tri-Counties Regional Center (TCRC) placed R1 at this facility in 06/2023 and the facility has had meetings with TCRC about R1. The most recent team meeting regarding R1 was held 05/01/2024 with facility Administrator, R1, TCRC and Behaviorist. Everyone is aware of R1 and the refusals to shower. The facility is currently working with TCRC on placement for R1. Based on the evidence this allegation is Unsubstantiated at this time. On the allegation: Facility staff do not ensure resident's hygiene needs are being met. Based on staff interviews R1 has been refusing showers. R1 is being changed several times thorough out the day. R1 is getting wiped down daily and R1 is getting sponged bathed Monday-Friday on a regular basis. R1 was showered recently on Noc shift early morning on the 12th by staff 5 (S5), R1 would not allow for R1's hair or face to be washed but allowed S5 to use a washcloth to clean R1's body, R1 was also given a wash cloth to help clean R1's self. Staff at the facility called 911 and R1 went to the ER later that afternoon on the 12th, the staff that came on duty felt R1 had not been cleaned since the prior day and was worried that R1 would have skin breakdown, sores and or sepsis. The discharge paperwork was reviewed by LPA and had no mention of neglect, sores or sepsis. The ER diagnosis was abdominal pain. The facility staff are working with TCRC and Behaviorist to help R1 with R1's changing behaviors. Continued 9099-C The facility has spoken with TCRc about possible placement of R1 to another facility. LPA spoke with TCRC Quality Assurance staff that stated they were made aware of the shower refusals and are now aware of the possible placement to another facility for R1. R1 is incontinent and R1 does refuse showers. The staff try daily to shower R1 and sometimes are not able to due to R1's refusal and agitation. Based on the evidence this allegation is deemed Unsubstantiated at this time Exit interview conducted and copy of report printed for Administratorthe state’s words, verbatim · CDSS document, May 21, 2024 · control 29-AS-20240513121541

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) De Leon conducted a case management visit to the facility above. LPA met with Kylan Reynoso and explained the purpose of the visit. During a complaint investigation LPA learned the facility has a current resident with dementia. The facility does not have an approved Plan of Operation with a Program Plan for Dementia residents. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, May 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(1-2) · Plan of correction due date: May 23, 2024

(b) ...Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:(1)Procedures for notifying...(2)Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic...This requirement has not been met as evidenced by: Based on record review the Licensee did not comply with the regulation above the facility does not have a plan of operation approved for dementia which poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: Licensee agreed to provide CCL with a addendum to the plan of operation adding a dementia program plan, if the program plan is not approved by CCL the facility will serve residents with Dementia a 60-day eviciton notice for relocation by TCRC.

Allegation investigated: Facility staff did not seek medical attention in a timely manner for resident in care.

At 8:30am on 01/26/2024, Licensing Program Analyst (LAP) Jeffries arrived unannounced at the facility to issue final findings to this complaint. LPA met with Administrator, Kyland Reynoso announced who he is and the reason for the visit. LPA issued final findings on a separate complaint for this facility on this same visit. As to the allegation of, “Facility staff did not seek medical attention in a timely manner for resident in care.” It was alleged that on 02/09/2023 Resident 1 (R1) was not provided timely medical attention. It was discovered through interviews and documentation that on 08/31/2023, R1 had a routine medical appointment with Dr. Bower, who ordered UTI test, where R1 left urine sample and follow-up scheduled medical appointment on 09/15/2023. On 09/16/2022, R1 had a comprehensive physical assessment (LIC602) completed by Hanah Rower, N.P. where R1 was documented to have a chronic bladder impairment (urine incontinent). On 12/19/2022, CONTINUED on LIC9099-C Unsubstantiated R1 had a surgery procedure of Prostate Transurethral Vaporization and returned to the facility with orders to proceed as normal, on 12/21/2022 R1 had surgery follow up visit, no issues reported. On 01/22/2023 R1 had a mobile dental hygiene visit. On 01/31/2023, R1 had an appointment with Urologist Dr. Perkins, who documented, “symptoms of decline” related to R1’s surgery on 12/19/2023. Interviews on 03/06/2023 of Staff 1 and 3 (S1, S3) indicated that R1 had maintained a baseline upon returning from surgery in January and never improved and declined gradually, despite being on antibiotics. S3 stated that R1 gradually declined and was taken to the Emergency Room (ER) on 02/09/2023 where R1 was diagnosed with a bladder urinary tract infection (UTI) then cleared by the ER to return to the facility. On 02/18/2023, S3 noticed increasing symptoms and took R1 to the ER, where R1 was admitted to the Hospital for observations. On 03/19/2023, R1 was placed on Hospice Care through Central Coast Hospice. On 03/31/2023, R1 succumbed to their illness and passed away on 03/31/2023. Additionally, facility documentation included daily temperature checks, medication checks, and sunscreen checks from January 2021 through February of 2023 excluding days spent in hospitalization. LPA noted that the decline in R1 due to of complications from the bladder infection based on documentation, medical assessments and staff interviews indicated a gradual decline in R1’s baseline ADL’s. Documentation, medical appointments, and Emergency Room visits show evidence of staff seeking medical attention in a timely manner due to the nature of the decline of R1. Additionally, LPA Jeffries contacted Tri Counties Regional Center and no significant findings in R1’s care at this facility from TCRC. . At this time there is not enough evidence to support the allegation of, “Facility staff did not seek medical attention in a timely manner for resident in care.” and is unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 29-AS-20230303132847

Allegation investigated: Due to insufficient staffing residents’ needs are not met. Staff do not have proper training. Facility has mold.

At 8:30am on 01/26/2024, Licensing Program Analyst (LAP) Jeffries arrived unannounced at the facility to issue final findings to this complaint. LPA met with Administrator, Kyland Reynoso announced who he is and the reason for the visit. LPA issued final findings on a separate complaint for this facility on this same visit. As to the allegation of, “Due to insufficient staffing resident’s needs are not met.” and “Staff do not have proper training. “It was alleged that resident’s needs were not being met during the AM shifts in the months of September and October 2023. It was discovered through documentation, and interviews that on as many as 15 A.M. shifts, according to documentation (09/07, 09/08, 09/12, 09/13, 09/14, 09/15, 09/26, 09/28, 09/29, 10/03, 10/05, 10/06, 10/17, 10/20, 10/24, and 10/25. All dates in 2023) between September and October 2023, Staff 1 (S1) had not met the regulations requirements of training to work without shadowing a tranined staff. According to interview by LPA on 11/02/2023 with S1, S1 was left alone with residents in care for which required residents transition from sleeping to getting ready to leave the facility for day program. CONTINUED on LIC9099-C Substantiated Records reviewed and collected on 11/02/2023 show that 1 of 4 residents have a diagnosis of dementia, and 4 of 4 residents require assistance in bathing, 1 of 4 are not able to bath themselves, as indicated residents Physician Orders (LIC602). On 11/02/2023 LPA Jeffries requested in report LIC9099, the following: “All staff of Facility, actual hours worked September - October 2023, -Job descriptions and job duties, -All staff training past 12 months. …” Facility Administrator only provided training for one staff (S1). The training records provide for S1 indicated the following training: Drivers Training 08/09/23, 1.5 hours, Med assist training 08/04/23, 4.5 hours, Orientation 07/28/23 5 hours, CPI (Crisis Prevention Institute) Online 09/23/23, 2.5 hours, CPI In-person, 09/23/23 6.25 hours. LPA noted that there was no indication of basic first aid, CPR (Cardio-Pulmonary Resuscitations), or dementia training for S1. On 01/25/2024 at 4:46PM, Executive Director, Sean Denich emailed LPA Jeffries with additional documentation which did not show any additional training for S1. Additionally, facility time records for the same months showed no different compelling findings than the original time sheet documents submitted at the beginning of this investigation. LPA conducted an interview with S1 on 11/02/2023, where S1 stated that they have been left alone with residents without any training for several days and some residents left for day programs without having time to eat breakfast. Based on documentation, and interviews, the allegations of, “Due to insufficient staffing resident’s needs are not met.” and “Staff do not have proper training. “ and both are substantiated at this time. As to the allegation of, “Facility has mold.” It was alleged that the facility had dangerous mold in the on-suite bathroom. On 11/02/2023 LPA Jeffries observed and photographed black mold on the bathroom vanity in facilities on-suite bathroom. LPA noted that before LPA to make the observation, facility maintenance personal S4, was observed walking out of the facility with two hands full of molded wallpaper, which matched the remnants of the wallpaper that was in the bathroom vanity. LPA noted that mold mediation was started on this date (11/02/2023). LPA interviewed S1 on 11/02/2023. S1 stated that they had reported the mold to the facility Administrator during the first week of September 2023. Based on observations, photographs, interviews, and mold mitigation efforts during the visit, there is enough evidence to support the allegation of, “Facility has mold.” and the allegation is substantiated at this time. Exit interview, report read, citations issued, appeal rights and report provided. Based on documentation, and interviews, there is not enough evidence to support the allegations of, “Staff did not provide medical attention to residents in a timely manner.” and “Staff did not assist residents with obtaining medical appointments.” and are both unsubstantiated at this time. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 29-AS-20231101111334

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.626(a)(1) · Plan of correction due date: Jan 29, 2024

1569.626 Training requirements for direct care staff (a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:(1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, … This requirement was not met by S1 being left alone and not properly trained, which poses an immediate danger to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Facility shall provide a list of all facility personnel and their training records to LPA within 24 hours of this report. Then formulate a training schedule that will have all facility personnel properly trained by regulation standards within two weeks of this report.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 29, 2024

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement was not met by evidence of time sheets and interviews that on at least 5 to 15 occasions there was only one staff without basic regulated training was on shift during 7am to 10am which puts resident in immediate danger.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Facility will create a more robust staff recruitment campaign, outlining additional steps the facility will take to recut more numbers and qualified staff then the current recruitment tools the facility employes. this recruitment campaign will be emailed to LPA by 02/09/2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a)(1) · Plan of correction due date: Jan 29, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met by evidence of black mold in the bathroom which poses an immediate danger to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Mold mitigation was started on 11/02/2023, LPA confirmed with photographs that mold mitigation was started. LPA was sent photographs of KILLZ paint applied to vanity. LPA was told by Executive Director that vanity would eventually be replaced. This POC is cleared and new LPA will follow up.