Chhina's Senior Guest House

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Eryn Kane conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Sukhminder Chhina, to whom LPA discussed the purpose of the visit. Jiwan Chhina, Administrator joined shortly after. According to the facility’s license, the facility has a maximum capacity of six (6) residents. During today’s inspection, six (6) residents were at home. LPA, accompanied by Administrator Chhina, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant at 78 F. Hot water temperature at taps accessible to residents were all compliant: Bathroom sinks were at 106.3 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed Administrator Chhina. Interview did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Confidential records were stored in locked areas. Staff had their first aid cards and background clearances in their files. During record review, two (2) of six (6) client files were observed to be missing required documents pertaining to annual resident appraisals and routine medical visits. LPA provided Administrator Chhina with information on resident appraisal regulations via email. Two deficiencies were observed and cited during today's visit. An exit interview was conducted with Administrator Chhina, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Tiffany Holmes and Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Kushpreet "Kush" Chhina, to whom LPAs discussed the purpose of the visit. Jiwan Chhina, Administrator arrived during the visit. According to the facility’s license, the facility has a maximum capacity of six (6) residents. During today’s inspection, five (5) residents were at home. There was one (1) resident on hospice. LPAs, accompanied by Kushpreet "Kush" Chhina, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant at 72 F. Hot water temperature at taps accessible to residents were all compliant: Bathroom sinks were 105.1 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] No pools or bodies of water on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed Chhina. Interview did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Client files were not missing required documents. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond. Staff had their first aid cards in their files. Deficiencies were observed and cited during today's visit. An exit interview was conducted with Chhina, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 8, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Jiwan Chhina, Administrator, to whom LPA discussed the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of six (6) residents. During today’s inspection, five (5) residents were at home. LPA, accompanied by Chhina, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant at 72 F. Hot water temperature at taps accessible to residents were all compliant: Bathroom sinks were 105.1 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] No pools or bodies of water on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed Chhina. Interview did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Client files were missing required documents. Confidential records were stored in locked areas. House Manager presented proof of current/active business liability insurance and surety bond. Staff had their first aid cards in their files. Deficiencies were observed and cited during today's visit. An exit interview was conducted with Chhina, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 28, 2024

Allegation investigated: Resident was not accorded the right to select their own health care provider.

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close out a complaint. LPA identified herself, was granted entry, and stated the purpose of the visit to Jiwan Chhina, Administrator. During the investigation, LPA toured the facility, conducted interviews and completed a records review. It was alleged that the resident was not accorded the right to select their own health care/hospice provider. Interviews revealed that the hospital decided for Resident 1(R1) which facility to go to because they have always done business with this facility. Interviews revealed when interviewed about hospice, interviews revealed the Administrator stated “if you’re going to stay here, you have to use our hospice agency”. When asked if they would have chosen something different, Interviews revealed that they werent sure because this is their first experience with hospice. Interviews revealed they were basically propositioned to choose the facility hospice agerncy and not one of their choosing. Interviews with the staff revealed that staff stated that the hospice agency Apriva is already coming to the facility so they will be there more. Interviews with staff revealed they told the nurse that they are not choosing for the resident and that the resident would need to be the one calling hospice. Interviews revealed that R1 is alert and oriented and capable of choosing a hospice agency. Interviews revealed R1 can choose any hospice agency, that is the resident’s right. A copy of this report and Licensee Appeal Rights (9058 03/22) were provided to Jiwan Chhina, Administrator after the conclusion of the visit, Substantiatedthe state’s words, verbatim · CDSS document, Aug 16, 2024 · control 08-AS-20221007143811

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 6, 2024

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 prior LPA interviews and outside witness interviews. the licensee did not ensure resident was able to make their own decision on medical provider for 1 out of 5 [R1] persons in care this poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2024

Plan of correction: Licensee and staff will have personal rights training by an outside source POC due to CCL by 09/06/2024. Licensee will submit sign in sheet & tranining documents by 09/06/2024

Allegation investigated: Centrally stored medications were accessible to residents. Facility used full bed rails for a non-hospice resident.

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to the facility to conclude a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Suki Chhina, Staff. The Department’s investigation consisted of staff, resident, and outside source interviews and a record review. It was alleged that centrally stored medications were accessible to residents. Interviews revealed and LPA observations on December 6, 2022 revealed an unlocked mini refrigerator behind the dining table in the kitchen that held medication unlocked. Interviews and observations revealed there was also medications on the dining room table that belonged to staff and residents. Substantiated Interviews revealed that staff was asked to put the medications away from an outside source and they did not do it. It was alleged that facility used full bed rails for a non-hospice resident. Interviews and prior LPA observations that took place on December 6, 2022 revealed they have a Doctors Order for full bed rails for room 6. Interviews revealed that the bed in room 4 had bed rails but they do not use the bedrails, interviews revealed they just haven't taken them off since the resident moved in back in 2019. Interview revealed that in room 5 they have half bed rails, in room 2 a bed with full bed rails, and room 3 had full bed rails; however, they were on Hospice. Based on evidence obtained, the allegations are substantiated because the preponderance of the evidence standard has been met. Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D. An exit interview was conducted with Licensee and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 03/22) were provided. Licensee signature below confirms receipt of the documents.the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 08-AS-20221128083012

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(2) · Plan of correction due date: Sep 6, 2024

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on prior LPA observations and outside witness interviews. the licensee did not ensure medications were inaccessible to 5 out of 5 [R1-R5] persons in care this poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2024

Plan of correction: Licensee did not have any medicaitons out on todays visit. Licensee and staff will have medication training and how to properly store medications by an outside source POC due to CCL by 09/06/2024. Licensee will submit sign in sheet & tranining documents by 09/06/2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608 · Plan of correction due date: Sep 6, 2024

B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on prior LPA observation, the licensee did not comply with the section cited above in 1 out of 5 (R1) residents did not have a hospice care plan that specified a full bed rail was needed or an approval from the Department which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 16, 2024

Plan of correction: Licensee does not have any bed rails on beds at this time except for 1. Licensee and staff will attend a Postural Support training. Proof of training due by POC due date 09/06/2024

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Debbie Correia and Daniel Pena conducted an unannounced visit to obtain signatures on an amended report. During today’s visit, LPAs were greeted by Caregiver Maria Marks identified themselves and met with Licensee Chhina and discussed the purpose of the visit. During today’s visit, LPAs obtained Licensee's signature on an amended version of a report originally delivered on February 27, 2024. An exit interview was conducted with Licensee Chhina, whose signature below confirms receipt of a copy of this report the (LIC 809) and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Mar 7, 2024

Type of visit: Office

An informal meeting was held via zoom with the San Diego Adult and Senior Care Regional Office. The following are the attendees of the virtual meeting: Associate Program Administrator (APA) Icela Estrada, Licensing Program Manager (LPM) Jennifer Lott, Licensing Program Analyst (LPA) Debbie Correia, and the Licensee. The purpose of this meeting was to develop Plans of Corrections (POCs) to address deficiencies that were deemed substantiated through a complaint investigation that was conducted by the Department. APA Estrada explained a POC is a collaborative effort between the Licensee and the LPA that needs to be developed by law, even if there is a disagreement regarding the investigation findings. During the meeting, the Licensee agreed that they and their staff will attend Community Care Licensing approved trainings that address the specifics of each regulation. APA Estrada also informed the Licensee that the report will notate the Licensee’s willingness to implement the POCs even though they disagree with the findings, per their request.the state’s words, verbatim · CDSS document, Mar 1, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to obtain signatures on an amended report. During today’s visit, LPA was greeted by the Licensee, identified herself and met with and discussed the purpose of the visit. During today’s visit, LPA obtained Licensee's signature on an amended version of a report originally delivered on February 27, 2024. An exit interview was conducted with Licensee Chhina and a copy of this report and the Licensee Appeal Rights (LIC 9058 3/22) were provided.the state’s words, verbatim · CDSS document, Feb 29, 2024

Allegation investigated: Staff neglect resulted in an amputation of a resident’s limb. Staff did not seek timely medical treatment. Staff did not meet resident’s needs. Staff did not meet resident’s incontinence care needs. Staff did not treat residents with dignity.

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to the facility to conclude a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Licensee Chhina. The Department’s investigation consisted of staff, resident, and outside source interviews. The investigation also consisted of facility, resident, and outside source records reviews. It was alleged that facility staff neglect resulted in an amputation of a resident’s limb, facility staff did not seek timely medical treatment, and facility staff did not meet resident’s needs, including incontinence care, and facility staff did not treat residents with dignity. A facility records reviews revealed Resident 1 (R1) was admitted to the facility on August 19, 2022. R1 was 77 years old at the time of admission and had a primary diagnosis of a Urinary Tract Infection (UTI) due to an enlarged prostate. R1 was also diagnosed with Type II Diabetes and required a Foley Catheter. This is an amended version of the original report dated 2/27/2024. Substantiated Hospital records dated August 14, 2022, revealed directly prior to R1’s admission to the facility they lived alone at their own place of residence and R1 sustained a fall while on a walk, resulting in a hospital admission. Hospital records revealed R1 sustained no injuries from the fall however revealed other health conditions, including the following diagnosis: Major Depressive Disorder, Diabetes Mellitus II with Chronic Kidney Disease at stage 3A and Dyslipidemia, Hypertension, Hypoglycemia, severe sepsis with acute organ dysfunction, generalized weakness, depression with Suicidal Ideation (SI), and general self-neglect. R1 also had a history of Brain Cancer, severe sepsis with organ dysfunction and a non-traumatic Kidney injury. Additional review of hospital records and an interview with Outside Source 1 (OS1) revealed an agreement that upon R1’s hospital discharge on August 19, 2022, they would be relocated to a Board and Care Facility. Further review of R1’s hospital records dated their day of discharge, August 19, 2022, revealed R1 had a skin assessment and was educated on skin care precautions including but not limited to; position change, screening for skin injury risk, such as pressure or moisture associated skin damage, keeping areas clean and dry, redistribution of pressure, floating heels off bed to avoid pressure on Achilles Tendon, encouraged ambulation, and to maintain hand hygiene and skin mucous membrane. On that same day, August 19, 2022, R1 was discharged from the hospital and transported to the facility. On August 22, 2022, R1 was assessed by a Home Health Agency (HHA) with services starting on August 30, 2022. A review of HHA records dated August 30, 2022, revealed they were assigned to, but not limited to, assist with the treatment of R1’s Diabetes and maintenance of R1’s Foley Catheter, provide Physical Therapy, educate staff on infection prevention and control, fall-risk prevention, how to monitor for pressure injuries on lower extremities, provide understanding and intervention for Diabetic foot care, instruction of pressure injury care per physician’s orders, signs and symptoms of a pressure injury and when to notify the physician. The HHA records dated August 30, 2022, also notated that R1 presented an unstageable pressure injury to their left heel. HHA records dated September 27, 2022, revealed R1 had developed a new pressure injury to their left ear, facility staff was educated on how to care for the pressure injuries during non-HHA nursing days. An interview conducted with R1 revealed when Staff 1 (S1) assisted R1 around September 1, 2022, in the shower they advised R1 that they observed skin peeling off R1’s left heel. R1 revealed they saw S1 a couple times a week and S1 changed and showered them. R1 also revealed facility staff had left them in soiled depends for approximately 2 hours on at least one occasion. An interview conducted with the Licensee revealed on approximately September 1, 2022, they were giving R1 a shower and saw something on R1’s heel, and that it was hot and red. The Licensee’s statement contradicts R1’s recollection of who was showering them on or about September 1, 2022. The Licensee revealed they did not conduct a re-appraisal however called and notified R1’s Responsible Party (RP) and then alleged that HHA staff did not conduct full body checks, they would only check R1’s medication, assisted with showers and leave, and they never provided any trainings or instructions regarding the care of R1’s pressure injury to their heel. The Licensee admitted to never asking HHA staff questions regarding R1’s injury and stated they took their word that it was nothing serious. The Licensee made these statements just after informing the Department they are a Registered Nurse (RN) themselves. The Licensee also revealed they never discussed or reported R1’s prohibited health condition because they never knew what stage the pressure injury was. Additionally, they could not provide any facility records regarding R1’s care plan, claiming the HHA took all R1’s paperwork. The Licensee also revealed on September 30, 2022, R1’s pressure injury was observed to be malodourous, and they had concern that R1’s foot was becoming gangrenous. An additional interview with Outside Source 2 (OS2) revealed the wound was unstageable due to it being covered by black eschar (dead skin). An interview conducted with facility Staff 2 (S2) revealed knowledge of R1’s pressure injury, S2 believed it was a Stage I or Stage II and revealed they never provided any wound care, or sought medical attention, and stated the care for R1’s pressure injury was provided by the HHA. An interview conducted with Staff 3 (S3) revealed they had worked at the facility for approximately 3 years, S3 also revealed knowledge of R1’s injury and that it was only treated by the HHA, also stating they were never provided instructions on how to care for R1’s injury. This is an amended version of the original report dated 2/27/2024. A review of HHA records revealed on September 26, 2022, they had just been approved to start caring for R1’s pressure injuries. HHA records also revealed providing facility staff education on proper Diabetic foot care and how to monitor for the presence of skin lesions. The records also included documentation of several other dates HHA staff provided facility staff education on how to care for R1’s foot. An interview with OS2 revealed that facility staff were provided verbal education/instructions on how to care for R1’s pressure injury located on their left heel. OS2 revealed having facility staff repeat back how they were to care for R1’s foot per their instructions. A review of additional hospital records revealed on October 1, 2022, R1 was admitted to the hospital after sustaining a fall at the facility resulting in no bodily injury. During hospitalization R1 told hospital staff they felt generally weaker than usual over the past two days and collapsed while trying to use the restroom. Hospital records also revealed R1 was notified by medical staff that their pressure injury on their left heel was so severe R1 faced an amputation or possible death. On October 2, 2022, R1 heel was lanced and drained and R1 was given a urine test and culture test of their heel and both tests returned positive for Multi Drug Resistant (MDR) Escherichia (E) Coli, a bacterium that is difficult to treat with standard anti-biotics and posed an increased mortality rate and significant public health concern. On October 4, 2022, the eschar (dead skin) was removed from the wound, on October 6, 2022, R1 was diagnosed with Osteomyelitis (a serious bone infection) of the left foot, and on the following day, October 7, 2022, R1 underwent an amputation of their left limb from below the knee. R1 was released to Post Acute agency for continued care post amputation and released back to the facility on November 4, 2022. A review of Post Acute Agency records revealed they strongly recommended R1 to relocate to a new facility but R1 and their RP strongly disagreed and were adamant R1 return to their prior placement. In addition, at the time of release the Post Acute Agency staff informed the Licensee R1 was COVID-19 positive and the Licensee agreed to follow CDC guidelines. A facility records review regarding an additional resident, Resident 2 (R2) revealed they were admitted to the facility on October 7, 2022, and had a diagnosis of Renal Cancer, Dementia, and Diabetes. At the time of admission R2 was receiving Hospice Services that would come to the facility 2-3 times a week to clean R2’s pressure injuries. Interviews with outside sources revealed instructing facility staff to prop R2 on their side to relieve pressure and they needed to reposition them every 2 hours. An interview with R2 revealed facility staff would reposition them, however they stopped, or gave up, and ended up buying them an air mattress. R2 also revealed they were notified by their servicing Hospice agency they had a Stage IV pressure injury. This is an amended version of the original report dated 2/27/2024 Additionally, during the interview with R2 they revealed facility staff would change their Depends once per day, and on occasion again at night. An interview with OS1 revealed they had found R2 sitting in soaked Depends on several occasions and had found fecal matter in R2’s wound. An interview conducted with Staff 4 (S4) revealed R2 was repositioned every two (2) hours and staff used props on their back and hip area to relieve pressure but R2 would roll over to being flat on their back, at the time of the interview R2 had already passed away. It regard to the allegation that facility staff did not treat residents with dignity/respect, an interview with OS1 revealed the Licensee was disrespectful towards R2 and they would have loud arguments. An interview conducted with R2 corroborated being yelled at by the Licensee but felt the rest of staff were nice. R2 revealed the Licensee did not like their criticism and would become angry and yell at them, they also revealed being left in bed all day and felt ignored. [See LIC 811 for Confidential Names] Based on evidence obtained, the allegations are substantiated because the preponderance of the evidence standard has been met. Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D. An exit interview was conducted with Licensee and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) were provided. Licensee signature below confirms receipt of the documents. This is an amended version of the original report dated 2/27/2024. It was also alleged facility staff was not giving medications as prescribed and an unskilled staff member was administering insulin injections to residents in care. An interview with an Outside Source 1 (OS1) revealed residents in care would report they did not receive their medications. The interview also revealed that during the Month of May of 2022, one of the facility owners was in the hospital, and the other co-owner’s whereabouts was unknown and during that time an individual, known to be a relative of the facility owner, who did not speak English, came to the facility, and OS1 observed them administer the residents in care their insulin injections. Interviews conducted with Residents 1 (R1) and Resident 3 (R3), both having a diagnosis of Diabetes, revealed no corroborating information or evidence of either an unknown individual administering insulin or missing administration of medications. It was alleged staff were not meeting the residents’ personal hygiene needs and the facility did not provide adequate amount of food for residents’ daily diet. An interview with OS1 revealed R3 complained about how often staff were assisting with grooming, more specifically assistance with hair washing. An interview conducted with R3 revealed being showered twice a week and likes living at the facility. Other resident interviews revealed no complaints regarding hygiene needs. An interview conducted with Resident 2 (R2) revealed they get enough food, additionally an interview conducted with R1 revealed they are never left feeling hungry. Based on the Department’s investigation the above-mentioned allegations were determined to be unsubstantiated. An unsubstantiated finding means the allegations may have happened or could be valid although there was not a preponderance of evidence to prove that the alleged violations occurred. LPA conducted an exit interview with LIcensee Chhina and was provided a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 01-2016) and signature on this report acknowledges receipt of the documents.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 08-AS-20221121104725

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Apr 5, 2024

Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical …care and provide for assistance in obtaining such care... The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including... life-threatening medical crisis.... This requirement was not met as evidenced by: This is an amended version of the original report dated 2/27/2024. The Licensee did not assist with or obtain immediate care for an injury resulting in the loss of a resident's 1 [R1] limb. This posed an immediate health risk to [R1] one out of 5 residents in care. This is an amended version of the original report dated 2/27/2024.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Although the Licensee does not agree with the finding, they are willing to attend (with all staff) a CCL approved training regarding a care plan to assist or obtain immediate medical care for residents facing an imminent health risk. Proof of training will be submitted by POC due date. This is an amended version of the original report dated 2/27/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 5, 2024

Basic services shall at a minimum include Care and supervision as defined..."Care and supervision" means the facility assumes...responsibility...to provide... ongoing assistance with activities of daily living without the resident’s physical health, mental health...or welfare... endangered. Assistance includes... personal care. This requirement was not met as evidenced by: This is an amended version of the original report dated 2/27/2024. The Licensee did not provide ongoing assistance without resident’s physical health endangered. This posed an immediate health risk to [R1], 1 out of 5 residents in care. This is an amended version of the original report dated 2/27/2024.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Although the Licensee does not agree with the finding, they are willing to attend (with all staff) a CCL approved training regarding care and supervision. Proof of training will be submitted by POC due date. This is an amended version of the original report dated 2/27/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2)(3) · Plan of correction due date: Apr 26, 2024

Managed Incontinence. The...Licensee shall be responsible for the following: Ensuring...incontinent residents are checked... time when they are known to be incontinent, including during the night. Ensuring that... residents are kept clean and dry, and...the facility remains free of odors from incontinence. requirement was not met by as evidenced by: This is an amended version of the original report dated 2/27/2024. Based on interviews conducted with outside sources and residents and facility and outside source records reviews the Licensee assist residents were checked during times known to be incontinent and kept clean and dry from incontinence. This posed a potential health risk to [R1 and R2], 2 out of 5 residents in care. This is an amended version of the original report dated 2/27/2024.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Licensee agreed to put a tracking system in place implementing a log of times and dates caregivers change briefs for residents that require incontinence care. The Licensee will provide proof of tracking logs by POC due date. This is an amended version of the original report dated 2/27/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 26, 2024

Personal Rights of Residents... 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 was not met as evidenced by: This is an amended version of the original report dated 2/27/2024. Based on resident and outside source interviews the Licensee did not treat residents with respect and dignity. This posed a potential personal rights violation to [R2], 1 out of 5 of residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Licensee and staff will attend a CCL approved training on resident's personal rights and will provide proof of attendance by POC due date. This is an amended version of the original report dated 2/27/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Mar 27, 2024

Personal Rights of Residents in All Facilities. 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 was not met as evidenced by: Based on resident and outside source interviews the Licensee did not treat residents with respect and dignity. This posed a potential personal rights violation to [R2], 1 out of 5 of residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Licensee and staff will attend a CCL approved training on resident's personal rights and proof of attendance by POC due date.