Caring Families-Bv1

Type of visit: Required - 1 Year

Unannounced Annual Inspection visit was made by Licensing Program Analysts (LPAs) Kimberly Viarella and Sommer Hayes to this facility on 04/21/25. LPAs identified themselves to the Caregiver on duty, explained the purpose of the visit, and asked to speak with Licensee/Administrator. Designee, per LIC 308 was called, Lorrena Goodenough, and they arrived 10 minutes later. A brief interview followed. Designee explained that the facility is currently going through a change of ownership. LPAs requested documentation notifying Community Care Licensing of the Change of Ownership. LPAs provided Designee with regulations regarding a change of ownership along with offering consultation services to assist with a streamlined transition. The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. LPAs observed packages that were not dated as required. LPA provided Technical Assistance. LPA inspected the resident 5 bedrooms. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time. LPA noted soap, paper towels, and trash cans in the bathrooms. The hot water temperature was measured at 105 degrees Fahrenheit and was in compliance. The fire extinguishers (2) were last serviced on 01/22/25 by River City Fire and were also in compliance. The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. LPA observed that all screens and gutters were in good repair. The LPA observed medications were stored in a large locked cabinet behind a locked door off the kitchen and inaccessible to residents in care. Medications were primarily the pill packs provided by the pharmacy. LPA reviewed storage, dosing, and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance. A file review was completed by the LPAs. LPAs reviewed a sample staff and resident files. Files reviewed were in compliance at the time of inspection. LPAs compared the LIC 500 (Staff Roster) with the Guardian roster to ensure that all staff had the appropriate background clearances to care for the residents. All were in compliance at the time of this inspection. LPAs were informed of a future change of administrator. LPAs provided a list of documents to be provided to licensing by the close of business on 4/25/25 Just prior to leaving the facility LPAs, observed a white oblong pill on the floor in the area where they were working. The pill was identified as a prescription medication. This deficiency was cited on the LIC 809 D page. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's inspection. A copy of this report was provided and an exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 21, 2025

Allegation investigated: Staff do not serve nutritious meals. Staff are not meeting residents' dental hygiene needs. Residents are left in soiled clothing. Staff are not meeting residents' grooming needs. Staff do not maintain accurate residents' records. Staff do not ensure that residents' bathrooms are clean. Staff do not notify responsible parties of incidents.

THIS REPORT IS AMENDED TO REMOVE THE ADDITIONAL NUMBER (1) FROM DATES REFLECTING IT TO READ 1/13/25. ADMINISTRATOR AGREED Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above-mentioned allegations on 1/13/25 at 8:45am. LPA met with Administrator Lorrena Lopez Goodenough, Administrator and stated the purpose of the visit. Regarding allegation, “Staff do not serve nutritious meals” During interviews of staff #1 (S1-S4) on 6/24/24 and 1/10/25 it was stated that the facilities main course which consists of a variety of foods is prepared off-site, and the sides are prepared on site. During interviews with responsible parties (RP1 – RP4) conducted on 1/13/25 revealed that there are a variety of meals and snacks provided for the residents. Based on interviews the preponderance of evidence standard has not been met. Unsubstantiated Regarding allegation, “Staff are not meeting residents' dental hygiene needs” During interviews of staff #1 (S1-S4) on 6/24/24 and 1/10/25 all corroborate that the residents all have hygiene care to include cleaning dentures in the morning and at night. During interviews with responsible parties (RP1 – RP4) conducted on 1/13/25 revealed that dental hygiene is being provided. One of the four responsible parties stated that hygiene could be better after meals. LPA observed the dentures of residents who are not using them during this time to be in denture cups with denture cleaning solution. Based on Observation and interviews the preponderance of evidence standard has not been met. Regarding allegation, “Residents are left in soiled clothing” During interviews of staff #1 (S1-S4) on 6/24/24 and 1/10/25 LPA observed that S1 stated laundry is done daily. S2-S4 stated clothes are checked and changed when needed and that residents are not left in soiled items. LPA conducted unannounced visits on 6/14/24, 6/18/24, 7/11/24, 1/10/25 and 1/13/25 and did not observe a foul odor in the facility nor on residents during the visits. During interviews with responsible parties (RP1 – RP4) conducted on 1/13/25 revealed that during unannounced visits, residents are not being left in soiled clothing and there is no foul odor present. Based on observations and interviews the preponderance of evidence standard has not been met. Regarding allegation, “Staff are not meeting residents' grooming needs” During interviews of staff #1 (S1-S4) on 6/24/24 and 1/10/25 LPA obtained information that the Chief Operating Officer (COO/S1) makes unannounced visits and finds the residents to be cared for and in good spirits. S2-S4 stated that residents have showers, skin care with lotion and facial hairs groomed. There is a schedule for everyone but sometimes residents refuse at which time another staff would try to assist in that area. LPA observed a copy of the shower schedule which indicates R1 gets a shower 3 times a week. LPA observed other facility records which document dates that residents receive showers, oral care, and weighed to determine weight gain or loss. During interviews with responsible parties (RP1 – RP4) conducted on 1/13/25 revealed that residents are receiving groom care with hair and nails. In regards to the nail care, the facility has a podiatrist who visits, some go out in the community, staff files nails, and some family assist with the nail care. Based on interviews the preponderance of evidence standard has not been met. Regarding allegation, “Staff do not maintain accurate residents' records” During interviews of staff #1 (S1-S4) on 6/24/24 and 1/10/25 LPA observed that staff are documenting Activities of Daily Living (ADLs) like medications, hygiene, bowel and urination, food, fluid, snacks, and weight. LPA observed facility records which document dates that residents receive showers, oral care, and weight gain or loss. During interviews with responsible parties (RP1 – RP4) conducted on 1/13/25 revealed that staff has been observed completing records or when asked has provided information regarding care from the records promptly. Based on interviews the preponderance of evidence standard has not been met. Regarding allegation, “Staff do not ensure that residents' bathrooms are clean” During interviews of staff #1 (S1-S4) on 6/24/24 and 1/10/25 LPA obtained information that the bathrooms are cleaned as needed and on every shift. During interviews with responsible parties (RP1 – RP4) conducted on 1/13/25 revealed that the bathrooms have new accessible showers, and toilets and that the bathrooms contain necessary toiletries and are clean. Based on interviews the preponderance of evidence standard has not been met. Regarding allegation, “Staff do not notify responsible parties of incidents” During interviews of staff #1 (S1-S4, S6) on 6/24/24 and 1/10/25 LPA observed that according to S6 some families are not responsive. S2-S4 stated that responsible parties are either contacted by the caregivers, Administrator, or Chief Operating Officer (COO/S1) which includes contacting 911 when things are serious. During interviews with responsible parties (RP1 – RP4) conducted on 1/13/25 revealed that all corroborate that staff are contacting them regarding incidents. Two out of the ten persons interviewed stated that contact was not made timely. A review of Incident reports submitted to Community Care Licensing indicate that staff is contacting the families and/or responsible parties regarding concerns with the residents. Based on interviews the preponderance of evidence standard has not been met. Based on observations, interviews conducted, and records review, it was determined that the preponderance of evidence standard is not met, therefore the allegations are deemed UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged incident occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Jan 13, 2025 · control 27-AS-20240613111755

Allegation investigated: Toilet, handwashing and bathing facilities are not being maintained in operating condition.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 7/11/24 at 12:50p. LPA was met by Caregiver Beatriz Hinojosa stating the purpose of the visit. Regarding allegation, “Toilet, handwashing and bathing facilities are not being maintained in operating condition. An interview with Bristol Hospice on 5/30/24 revealed that nothing was observed broken. An interview with LPA Ruth Wallace revealed the tub knob was working but needed a screw. S3 stated that the toilet lid was cracked, and was replaced. S1 stated the toilet was not broken but wobbly and just needed to be tightened. The Administrator admitted the toilet lid was cracked, and the screw for tub knob and the shower mat was all replaced. Based on interviews, observation of receipt, and admittance by Administrator the above allegation is SUBSTANTIATED. This finding means the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs), Title 22, Div 6, Ch8, the deficiency is cited on the 9099D. A copy of their rights (LIC9058) provided and their signature acknowledges receipt of these rights. Exit interview conducted via telephone and a copy of report was provided via email and an electronic email read receipt confirms receiving these documents. Substantiated During the initial complaint visit on 2/3/24, LPA Ruth Wallace obtained a copy of a CA Food Handler Card effective 11/21/22 – 11/20/25 for witness#1 (W1). LPA Brown observed the food handler card that was in place prior to Community Care Licensing (CCL) receiving this complaint allegation. LPA Brown conducted interviews of R1-R5 on 6/18/24 which revealed that due to cognitive issues residents could not reasonably answer interview questions. However, R5 and R6 was able to state the food was good. An inquiry with Sutter Health revealed that for hospice residents, there are a lot of factors involved and it doesn’t equate to pounds although it is a decline, some are unable to be weighed, and a circumference measurement is taken of the left upper arm. The several factors involved are eating habits, diagnosis, edema, and diuretics. An interview with Bristol Hospice revealed that some residents on hospice has gained weight while others lost weight. And that this is not due to a food issue. An interview with LPA Ruth Wallace confirmed that the cook who prepares the main course for the meals has a current food handler certification. The food is prepared, frozen and transported to the facility. LPA Victoria Brown observed during visits on 5/30/24 and 6/18/24, that the main courses are frozen, labeled, dated, and contains instructions for cooking. S3 stated that unannounced visits are conducted to the kitchen and the facilities. All food is prepped according to all regulations. S2 stated the food is always a different variety. 1 of 4 of the responsible parties stated the quality of food has gone down in the past few months. The rest of the responsible parties stated the residents are given fresh fruits and vegetables as well as a variety of meals and there is not an issue with the food. Regarding allegation, “Staff is not properly cleaning and sanitizing dishes and other utensils. An interview with LPA Ruth Wallace revealed that the staff uses the dishwasher. S1 stated the dishwasher is always used. The responsible parties also stated the dishwasher is used by some and others washed the dishes by hand. Interviews on 5/30/24 and 6/18/24, all concur the dishes are not dirty nor broken and LPA Brown did not observe dirty dishes during the visits. S2 stated the dishwasher is used and there are no broken dishes. S3 stated the dishwasher has not needed repairs and it has its own water heater. The Administrator stated staff either wash the dishes or use the dishwasher. Based on interviews, the preponderance of evidence standards has not been met. The allegations are deemed UNFOUNDED. “This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.” An exit interview was conducted with Lorrena Goodenough via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 27-AS-20240201081455

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 11, 2024

Maintenance and Operation 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 This requirement is not met as evidenced by:Based on admittance the licensee did not replace the items needing repair timely. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 11, 2024

Plan of correction: Licensee replaced the toilet, shower mat and repaired the tub knob. POC cleared prior to todays visit Additionally, continue working with contractor to secure a test date for mold. The results shall be faxed to CCL upon completion.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 year Annual Inspection Visit. LPA met with Administrator and explained purpose of visit. Administrator certificate expires 1/29/2025. LPA and administrator inspected physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature measured at 112.6 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers were inspected on 11/23/2024. Smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to clients. LPA reviewed Fingerprint clearance and associations to the facility. Common touch surfaces are cleaned after each use. Fire drill last conducted on 12/19/2023. LPA reviewed three resident and five staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete. LPA received the following updated forms on today's date: LIC 308, Liability insurance Certificate, and Administrator Certificate. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted with administrator. A copy of this report and LIC 811(Confidential Names) was left with administrator at the facility.the state’s words, verbatim · CDSS document, Feb 3, 2024