Care Juliet 1

Allegation investigated: Facility has fire hazards.

Licensing Program Analyst (LPA) Jessica Cho made an uannounced visit for the purpose to conduct a complaint investigation into the above allegation. LPA was greeted and granted entry by House Manager (HM) Juileta Cervania and stated the purpose of the visit. LPA also met with Caregivers Janella Cervania and Bayani Villarosa. LPA spoke to Administrator (Admin) Lester Del Rosario via a telephone call approximately 9:55am and received consent for HM to sign the report on his behalf. During the course of the investigation, LPA observed six residents in care, toured the physical plant including the patio, interviewed residents/staff, and obtained pertinent resident records. The following are the findings which involved observations, record review, and interviews: It was alleged that facility has fire hazards. LPA along with HM Cervania observed the presence of the Additional Dwelling Unit (ADU) located in the patio area and observed that it was being occupied by Caregiver #2 (C2) as their primary residence. Substantiated The Administrator corroborated that the addition of the ADU was not cleared by the Orange County Fire Department and is a suspected fire hazard that may affect the health and safety to the residents. Therefore, based on the observations and the interviews which were conducted, the preponderance of evidence standard has been met, therefore the allegation: facility has fire hazards is deemed SUBSTANTIATED as per Title 22 of the California Code of Regulations, Division 6, Chapter 8. A citation is being issued on the attached LIC9099D. An exit interview was conducted with House Manager Julieta Cervania, and a copy of this report including the LIC 9099C, LIC9099D, and the appeal rights were provided during today's visit.the state’s words, verbatim · CDSS document, Jul 21, 2023 · control 22-AS-20230714131232

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(b) · Plan of correction due date: Jul 27, 2023

87305 Alterations to Existing Building or New Facilities (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. This requirement was not met as evidenced by: Based on LPA's observations and interviews, Administrator corroborated that the dwelling unit was not cleared by the fire department which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2023

Plan of correction: Administrator to submit a LIC200 and updated outdoor facility sketch to LPA via email by POC due date.

Allegation investigated: Untrained staff

Licensing Program Analyst (LPA) Jerome Haley made an unannounced initial 10-day visit regarding the complaint allegation listed above. LPA identified himself and explained the reason for the visit with staff who called Administraotr (AD) John Del Rosario via telephone who arrived a short time later. Before interviewing residents and staff to gather details, LPA Haley toured the interior and exterior of the facility with Staff 1 (S1). Regarding the allegations, “Untrained staff” The investigation revealed the following: During the initial visit May 1, 2023, LPA Haley toured the facility and conducted interviewes with the Administrator, 2 staff and 4 residents. During the interview with Staff 2 (S2), S2 stated he was new and he has not received/started any training yet. S2 did mention he's only shadowing right now and explained what he's learned. After the interview, LPA Haley asked AD Del Rosario about training for S2 and asked to review training records for S2. There were no trining records available for S2. Continued on LIC9099C Substantiated There was only a live scan and personnel record (LIC501) available for review. AD Del Rosario stated S2 has only been shadowing since he started. AD Del Rosario was unclear of the status of S2s training because AD Del Rosario had to asked S2 did he begin online training, while LPA Haley was present and S2 said "No." LPA Haley asked AD Del Rosario has the shadowing S2 has done been documented? Is the on the job training (shadowing) being documented? LPA Haley also asked are there any descriptions of the shadow training S2 has received? AD Del Rosario was no. Nothing has been documented regarding the training for S2. Based on the evidence gathered, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1. An exit interview was conducted and a copy of this report, LIC9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, May 1, 2023 · control 22-AS-20230427090922

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c)(6) · Plan of correction due date: May 1, 2023

Personnel Requirements - General The licensee shall maintain documentation pertaining to staff training... as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer,... covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement is not being met as evidenced by interview confirmation with the facility administrator and staff file review. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 1, 2023

Plan of correction: Administrator will read and review Regulation 87411 and send LPA Haley an email confirming the regulation has been read and understood. Administrator Del Rroasrio will also email a breakdown of the shadow training completed by S2, who S2 shadowded, and how much time S2 was trained on each topic. AD Del Rosario will also have Staff 2 start the required 20 hours of online training and email LPA proof online training has started with an estimated complation date. POC due date is Wednesday, May 3, 2023 at 12 noon.

Allegation investigated: Staff failed to provide a safe and comfortable environment for residents Staff are unable to communicate with residents due to language barrier

Licensing Program Analyst (LPA) Jerome Haley made an unannounced initial 10-day visit regarding the complaint allegations listed above. LPA identified himself and explained the reason for the visit with staff who called Administraotr (AD) John Del Rosario via telephone who arrived a short time later. Before interviewing residents and staff to gather details, LPA Haley toured the interior and exterior of the facility with Staff 1 (S1). Regarding the allegations, “Staff failed to provide a safe and comfortable environment for residents” The investigation revealed the following: During the initial visit May 1, 2023, LPA Haley toured the facility and observed all six residents in care. The facility was observed to be clean and well organized. During the visit LPA Haley interviewed AD Del Rosario, two staff, and four residents. 4 of 4 reisdents interviewed denied the allegation above. 2 of 2 staff and AD Del Rosario denied the allegation above. Continued on LIC9099C Unfounded Regarding the allegations, “Staff are unable to communicate with residents due to language barrier” The investigation revealed the following: During the visit, LPA Haley conducted interviews with AD Del Rosario, and both staff member in English without any communication issues noted during the visit or interviews. 4 of 4 residents interviewed during the visit denied the allegation above. AD Del Rosario denied the allegation and both staff members denied the allegation as well. Based on the information gathered during the investigation, observation, and review of all documents obtained, the following allegations: "Staff failed to provide a safe and comfortable environment for residents", and "Staff are unable to communicate with residents due to language barrier" is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 1, 2023 · control 22-AS-20230427090922

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced Case Management visit in conjunction with complaint visit 22-AS-20230123111444. LPA Ramirez was greeted and granted entry into the facility and initially met with Caregiver Janella Cervania and explained the reason for the visit. Administrator (AD) Lester A. Del Rosario arrived shortly after. During the course of the complaint investigation, LPA reviewed included the Identification and Emergency Information (LIC601) for six residents in care. Per LIC601 three of six residents are under the age of 60. The purpose of this Case Management visit was because the facility is retaining more than one person under the age of 60. Based on today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with AD Del Rosario and a copy was provided as well as Appeal Rights.the state’s words, verbatim · CDSS document, Mar 2, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87455(b)(7) · Plan of correction due date: Mar 10, 2023

Acceptance and Retention Limitations (b) The following persons may be accepted or retained in the facility: (7) Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility. This requirement is not met as evidence by: facility is retaining more than one person under the age of 60 without an approved Age Exception letter. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2023

Plan of correction: Licensee to submit an Age Exception Letter to LPA or Issue a 30-Day Eviction notice by POC due date.

Allegation investigated: Facility staff does not lock residents' medications at the facility.

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Andrea Mendivil conducted an unannounced complaint visit to deliver findings on the above allegation received on 01/19/23. LPAs were greeted and granted entry into the facility and initially met with caregiver Julieta Cervania. LPAs explained the reason for the visit. Administrator (AD) Lester A. Del Rosario arrrived shortly after. This agency has investigated the complaint alleging that facility staff does not lock residents’ medications at the facility. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: During the initial visit conducted on 01/26/23 and visit conducted on 02/03/23 LPA Ramirez observed resident’s medications to be centrally stored and locked inaccessible to others. Two of twelve individuals interviewed corroborated the allegation; However, six of twelve individuals reported medications get locked in the kitchen cabinet. Two of six residents reported not being aware of where medications are kept. The remaining two residents interviewed either could not be qualified and/or refused to answer questions. Unsubstantiated Six of six resident files reviewed indicate that residents are not able to administer own prescription medications. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA Ramirez conducted an exit interview with AD Del Rosario, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 3, 2023 · control 22-AS-20230119084106

Allegation investigated: Facility staff mismanaged resident's medications.

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Andrea Mendivil conducted an unannounced complaint visit to deliver findings on the above allegation received on 01/19/23. LPAs were greeted and granted entry into the facility and initially met with caregiver Julieta Cervania. LPAs explained the reason for the visit. Administrator (AD) Lester A. Del Rosario arrrived shortly after. This agency has investigated the complaint alleging that facility staff mismanaged resident’s medications. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Four of six residents interviewed reported that the facility manages their medication. The remaining two residents interviewed either could not be qualified and/or refused to answer questions. Six of six resident files reviewed indicate that residents are not able to administer their own prescription medications. During the interviews Staff 1 (S1) reported that she is in-charge of passing medications and that she prepares medication for “three days” in advance and places it in “individual closing containers.” Substantiated Per witnesses interviewed, it was reported that Resident 1 (R1) was given pre-poured medications labeled with the wrong time and labeled with another resident’s name. During the initial visit conducted on 01/26/23 LPA Ramirez observed ready to dispense medication in small labeled seven-day plastic pill organizers. Based on the observations, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: facility staff mismanaged resident’s medications is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with AD Del Rosario and a copy of this report along with the LIC 811, and the Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Feb 3, 2023 · control 22-AS-20230119084106

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Feb 6, 2023

The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as eveidence by: Based on observation, Licensee failed to manage medications properly. It was reported that Resident 1 (R1) was given pre-poured medications labeled with the wrong time and labeled with another resident’s name.the state’s words, verbatim · CDSS document, Feb 3, 2023

Plan of correction: Licensee to conduct in-house training on how to properly manage centrally stored medications. LIcensee to forward POC by 02/06/23.

Allegation investigated: Staff are forcing the residents to participate in undesired activities.

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Andrea Mendivil conducted an unannounced complaint visit to deliver findings on the above allegation received on 01/23/23. LPAs were greeted and granted entry into the facility and initially met with caregiver Julieta Cervania. LPAs explained the reason for the visit. Administrator (AD) Lester A. Del Rosario arrrived shortly after. This agency has investigated the complaint alleging that facility staff are forcing the residents to participate in undesired activities. LPA Ramirez conducted interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Four of six residents interviewed reported that activities are “always voluntary” and “never” feel forced to participate in activities. The remaining two residents interviewed either could not be qualified and/or refused to answer questions. Four of four staff interviewed reported “never” witnessing residents being forced to participate in undesired activities. Records reviewed included the Activities calendar. LPA obtained Activities calendar for January and February, which includes numerous activities including but not limited to Zumba, music therapy, stretching exercises and social time. Unfounded Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA Ramirez conducted an exit interview with AD Del Rosario, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 3, 2023 · control 22-AS-20230123111444

Type of visit: Required - 1 Year

On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Caregiver (CG) Julieta Cervania. LPA Rosie Quiroz explained the nature of the visit. Administrator Lester DelRosario arrived shortly after. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to Age range 60 and over, 6 Non Ambulatory residents, and has a Hospice Waiver for 6 residents. Facility is currently providing services to zero (0) residents on hospice and three (3) resident on Assisted Living Waiver program. Administrator Lester DelRosario has a current Administrator certificate with expiration date of June 16, 2022. On or about 3:36pm, LPA Rosie Quiroz along with (CG) Julieta Cervania began the tour of the inside and outside of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed Resident 1 and Resident 2 in living room area resting, Resident 3 and Resident 4 in front porch area conversing and Resident 5 and Resident 6 in their bedrooms watching television. LPA Quiroz interacted and interviewed with residents during today's visit. Six of six residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 75 degrees fahrenheit. All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within 110-110.2 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating area for residents and visitor's enjoyment in backyard and front porch area. The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on March 05, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated March 05, 2021. Continued on next page... LPA Quiroz was informed that all residents and staff have had their COVID-19 vaccinations and first Booster and will be speaking to resident's families and pharmacy about second booster vaccination. Facility indicated to be recording resident's temperatures twice daily. During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit. Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. Technical Violation LIC 9102TV for (87705)(5) was issued on today's date, and discussed with (AD) Lester Del Rosario. This report was reviewed with (AD) Lester DelRosario, and a copy of this report, LIC 9102TV and LIC 811 Confidential Names were provided at exit.the state’s words, verbatim · CDSS document, May 23, 2022