Casa De Castro II

Allegation investigated: Licensee did not provide a safe environment for resident in care.

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to conclude a complaint investigation and deliver investigative finding in response to the above-listed allegation. LPA identified herself, was granted entry, and stated the purpose of the visit to Emelita Supnet, staff. Cheryl Castro, Licensee, was contacted via telephone. Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of a tour of the facility and interviews with facility staff and outside source. It was alleged that a safe environment was not provided to a resident in care when Resident 1 (R1) engaged in a behavioral disturbance in the home, during which R1 attempted to enter another resident’s bedroom, threatened, and attempted to attack the resident. Interviews conducted during the investigation confirmed that R1 had a behavioral episode in the early morning hours on March 29, 2023. Interviews further revealed Unfounded that, during the incident, R1 attempted to enter the bedroom of facility staff and directed aggression toward and targeted a staff who was in the staff bedroom. It was discovered that other residents in the home were in their respective bedrooms when the incident occurred, and no residents were verbally or physically targeted during the incident. The investigation yielded that R1 had calmed down and returned to baseline shortly after the incident occurred. The investigation also yielded that R1 was transported from the home the same morning without incidence or harm to any other residents in care. Based upon the foregoing, which reflects that a staff, not a resident, was the target of the reported incident, the complaint allegation is unfounded, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, as to the above listed allegation, based on information obtained, the facility is in compliance with Title 22 regulations at this time, and the complaint has been dismissed. An exit interview was conducted, via telephone, with Cheryl Castro, and copies of this report and Licensee/Appeal Rights (LIC9058) were provided to staff at the conclusion of the visit. Emelita Supnet's signature on this report acknowledges receipt of copies of the rights and report.the state’s words, verbatim · CDSS document, Apr 28, 2023 · control 08-AS-20230403142252

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dawn Segura conducted a case management visit to cite for deficiencies observed during a complaint investigation. LPA spoke with Cheryl Castro, via telephone, with whom she discussed the purpose of the visit. During a complaint investigation, LPA discovered, through interviews, that Resident 1 (R1) [LIC 811 Confidential Names List was provided to identify the resident] was transported from the home by the Psychiatric Emergency Response Team following a behavioral incident that occurred on or about March 29, 2023. R1 was transported to a local hospital. Interviews revealed that, several hours later, the facility’s licensee was contacted by the hospital staff, and the licensee was asked whether R1 would be accepted back into the home once he/she was settled. At that time, the licensee informed hospital staff that R1 would not be accepted back into the home; no notice of eviction had been provided to the resident. Subsequently, R1 was admitted into the hospital and remained there until hospital staff found another place to which R1 could be discharged. While conducting the same complaint investigation, during a review of records maintained by the facility, LPA discovered that licensee had been provided hospital records which reflect that prior to R1’s admission into the facility, which occurred on December 13, 2022, R1 was admitted into a local hospital on October 24, 2022, for dementia with behavioral disturbance. It is noted in the records that R1 was admitted on a 5150 (involuntary 72-hour psychiatric hospitalization) hold because R1 was determined to be a danger to others. It was also noted in hospital records that R1 would be evaluated for adjustment of psychotropic medications and to prevent immediate danger to self or others. The records reflect that R1 remained in the hospital until discharged to the facility on December 13, 2022. LPA reviewed the preplacement appraisal completed by licensee, dated December 13, 2022, and observed that the preplacement appraisal reflects that R1 has a diagnosis of dementia and is confused; however, the appraisal reflects no indication of behavioral disturbance or any type of psychiatric incident(s) or hospitalization(s) associated with R1 or in R1’s history. Additionally, while conducting the complaint investigation, during a visit to the facility conducted on April 11, 2023, LPA requested to review staff training records. A review of records present at the facility at the time of the visit reflected that the most recent dementia training received by Staff 1 (S1) and Staff 2 (S2) was on January 23 and 24 of 2018. Based upon the foregoing, deficiencies are being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on an LIC 809-D. An exit interview was conducted, and this report was discussed, via telephone, with Cheryl Castro. Copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to staff at the conclusion of the visit, and Emelita Supnet's signature on this form acknowledges receipt of the rights and a copy of this report.the state’s words, verbatim · CDSS document, Apr 28, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: May 26, 2023

Eviction Procedures. The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidenced by: Based on interview, the licensee did not issue 30 days written notice to R1, 1 of 6 residents in care, prior to eviction. This posed a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Apr 28, 2023

Plan of correction: Licensee offered to ensure that both administrators receive outside vendor training on proper eviction procedures in accordance with Title 22 regulations. Licensee agreed to provide proof of training to Community Care Licensing by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(c)(1) · Plan of correction due date: May 26, 2023

Pre-Admission Appraisal – General. Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs…(1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors…This req’t was not met as evidenced by: Based on records review, the licensee did not include an evaluation of 1 of 6 residents’ (R1) mental condition in the pre-admission appraisal. This posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 28, 2023

Plan of correction: Licensee offered to ensure that both administrators receive outside vendor training on conducting thorough assessments and documenting appraisals in accordance with Title 22 regulations. Licensee agreed to provide proof of training to Community Care Licensing by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87707(a)(2) · Plan of correction due date: May 26, 2023

Training Requirements. Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period. This requirement was not met, as evidenced by: Based upon a review of records, licensee did not ensure that S1 and S2 had dementia training within the last 12-month period. This posed potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Apr 28, 2023

Plan of correction: Licensee agreed to ensure that all staff receive and complete dementia training, as required by Title 22 regulations, and to provide proof of training to Community Care Licensing by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dawn Segura visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility by Emelita Supnet, Staff, to whom she disclosed the purpose of the visit. During today's visit, LPA toured the facility and verified compliance with infection control practices. LPA observed one central entry point for universal entry screening; temperature check initiated at entry for staff, residents, and visitors; a sign-in policy enacted for visitors; signs in the facility to promote hand hygiene, cough/sneeze etiquette, symptom and transmission awareness; face coverings worn by staff; hand sanitizer/hand washing stations readily available; available visitation area; emergency agencies’ contact information visible to staff; and an ample supply of cleaning products and PPE. No deficiencies were cited during today’s visit. An exit interview was conducted with Emelita Supnet, Staff, and copies of this report and Licensee Rights (LIC 9058) were provided to the staff at the conclusion of the visit. Emelita Supnet's signature on this form acknowledges receipt of the rights and a copy of the report.the state’s words, verbatim · CDSS document, Aug 19, 2022

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not dispose of rodent

Licensing Program Analyst (LPA), Marisela Garcia-Centeno, conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegation. LPA identified herself and was granted entry by Caregiver, Emelita Supnet. LPA stated the purpose of the visit and reviewed the basic elements of the complaint with Administrator, Celeste Castro. During the visit, LPA Garcia-Centeno conducted a tour of inside and outside of the facility with Caregiver, Supnet. LPA interviewed staff and briefly interacted with residents in care. Based on observations and interviews with staff and outside sources, the allegation was determined to be unsubstantiated as the preponderance evidence standard was not met. An exit interview was conducted, and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Administrator, Castro, via email. An electronic email receipt confirms the documents were received. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 3, 2022 · control 08-AS-20220228112059

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Alexandre Vo, conducted an unannounced annual required licensing inspection. LPA was granted entry by Licensee, Cheryl Castro, after identifying himself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with infection control practices. The tour was conducted with the Licensee. LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Infection Control, including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility's Plans for Infection Control and Physical Distancing, and Memory Care. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety. LPA reviewed items pertaining to central entry points for universal entry screening; routine symptom screening initiated for staff, residents and visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and clients; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and clients; and an adequate supply of PPE. No deficiencies were cited during this visit. Technical assistance (TA) was provided regarding documenting routine/daily symptom screening, hand sanitation signs, updated visitation policy and sign-in along with contact information and vaccine verification, and N-95 fit-testing per PIN 21-10-ASC. TA's are listed on the accompanying 9102. An exit interview was conducted with the Licensed. A copy of this report, along with the Licensee Rights (9058 01/16) were provided to the Licensee via e-mail. A confirmation e-mail was requested.the state’s words, verbatim · CDSS document, Sep 29, 2021

The state marks this report as 8 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.