Comfort Zone Cal

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Deficiencies inspection. At 10:55 a.m., the LPA met with staff and explained the reason for the visit. At 12:34 p.m., the Licensee Akhtar Roshanaeian arrived at the facility. The reason for today's inspection is to follow up on a self-reported incident dated 10/18/2023. The report pertains to the absent without official leave (AWOL) of Resident #1 (R1). On 10/17/2023, R1 left the facility despite caregivers attempting to redirect R1. The Administrator at the time notified R1’s family and the police. At the time of the visit, R1 still has not been located but the family are aware of the AWOL. At 11:30 a.m., the LPA conducted a record review of resident records. At 1:30 p.m., the LPA, along with the Licensee conducted a brief physical plant tour. During the time of the visit, the LPA requested copies of pertinent documents. Prior to visit, the LPA printed out the facility personnel report summary from the Licensing Information System (LIS). Upon arrival, it was revealed Staff #1 (S1) was recently hired. Per record review, conducted by the LPA on the Guardian Background Check System website, S1 does have fingerprint clearance but is not associated with this facility. Interviews with the Licensee and staff revealed that S1 started working at this facility on 11/01/2023. The Licensee stated that she will ensure that all staff will have a criminal record clearance and are associated to the facility prior to working at the facility. During record review the following was noted: R1, Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) did not have resident files nor completed files available at the facility. Per incident report, R1 was admitted to the facility on 10/10/2023. R2 was admitted to the facility on 09/12/2023, R3 was admitted to the facility on 09/15/2023 and R4 was admitted to the facility on 10/31/2023. The Licensee stated that she will ensure that all residents will have completed files. Continued on LIC 809-C. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $100. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of today's reports and appeal rights were provided. Civil penalties issued. An additional report may follow if warranted.the state’s words, verbatim · CDSS document, Nov 1, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Nov 2, 2023

87355(e)(2) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health… shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement is not met as evidenced by: Based on record review and interview the Licensee did not comply with the section cited by not transferring the criminal record clearance for S1 to this facility prior to employment which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: Licensee agreed to submit a transfer of a criminal record clearance for all staff not associated to the facility by 11/02/2023. Civil Penalties assessed in the amount of $100.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Nov 17, 2023

87506(a) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility…readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on record review, the Licensee did not comply with the section cited above as there were no files or incomplete files present at the facility for R1, R2, R3 and R4 which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: The Licensee stated that she will ensure that all residents will have completed files by due date.

Allegation investigated: Licensee neglect resulted in resident sustaining injuries while in care

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 03/16/2023 by LPA Arroyo. On today’s visit, LPA Arroyo met with Administrator, Hripsime Tavitian and the reason for the visit was explained. Entrance interview. During the initial visit on 03/16/2023, LPA Arroyo toured the facility at 11:22am, conducted interviews with the Administrator, one staff, and one resident between 10:03am and 11:05am, and conducted a record review and obtained copies of pertinent documents at 10:38am. The LPA also obtained copies of medical documents on 04/10/2023 and conducted a telephonic interview with resident's family member on 04/18/2023 at 12:48pm. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that licensee neglect resulted in resident sustaining injuries while in care. It was reported that Resident #1 (R1) had an unwitnessed ground level fall while living at the facility resulting in R1 obtaining a potential subdermal hematoma and subarachnoid hemorrhage. Additionally, RP had concerns because R1 had had two (2) within a few days. Review of documents revealed that on R1’s Physician’s Report dated 02/22/2023, indicates R1 is non-ambulatory and is able to independently transfer to and from bed. Correspondingly, R1 was able to walk around with a walker. Interviews with staff revealed R1 tried to get out of bed at night that resulted in R1 having an unwitnessed fall. The staff stated hearing a loud noise which prompted them to check on R1. Staff added that R1 usually called staff when they needed assistance. Interview with resident revealed facility staff often come inside the rooms and check on the residents and stated they have no concerns living at the facility. Additionally, interviews conducted with R1’s family revealed the facility had contacted and reported the falls shortly after they had happened. R1’s family stated that before R1’s first fall, both R1’s family and facility had made a request to attempt and have R1’s Primary Care Physician (PCP) order rails to be placed on the side of R1’s bed; however, R1’s PCP was not responding to the request and was taking too long for the approval. Furthermore, R1’s family stated they do not feel there was any type of neglect from the staff or facility. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “licensee neglect resulted in resident sustaining injuries while in care”. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was issued to the Administrator.the state’s words, verbatim · CDSS document, Apr 20, 2023 · control 29-AS-20230309110540

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20230309110540). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation. During the complaint investigation of complaint # 29-AS-20230309110540, the following deficiency was observed: On 02/27/2023, Resident #1 (R1) suffered an unwitnessed fall in the middle of the night which resulted in R1 suffering from a subdermal hematoma and subarachnoid hemorrhage. Staff dialed 9-1-1 and called for an ambulance as R1 was observed on the floor with blood on their head. R1 was ultimately taken out of the facility and hospitalized due to the fall. Record review and interviews conducted revealed that neither incident was reported to Community Care Licensing (CCL) or the serious incident/injury report (LIC 624) was submitted to CCL within seven (7) days of occurrence as required by the California Code of Regulations. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit Interview. Citation issued. A copy of the report and appeal rights were issued to the Administrator.the state’s words, verbatim · CDSS document, Apr 20, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 24, 2023

87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on interviews and documents reviewed, the licensee did not comply with the section cited above as the facility did not submit the unusual incent/injury report for R1 within 7 days of occurrence to CCL, which poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: POC: The Licensee will submit a plan detailing how the facility will maintain in compliance of Regulation 87211 and submit to CCL by 04/24/2023.

Type of visit: Collateral

Licensing Program Analyst (LPA) Emily Peraldi arrived unannounced for a Collateral visit. At 10:30 a.m., the LPA met with staff and explained the reason for the visit. Today's inspection is in regard to the investigation of complaint control 29-AS-20230222095031 which is unrelated to this facility. No health and safety concerns were observed during this visit. Exit interview conducted.the state’s words, verbatim · CDSS document, Mar 1, 2023

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Emily Peraldi and Ashley Smith conducted a pre-licensing visit to the above noted facility. The initial pre-licensing visit took place on 01/30/2023 and corrections were required. The LPAs met with Akhtar Roshanaeian and Hripsime 'Ripa' Tavitian and explained the reason for the visit. On 01/30/2023, LPA Emily Peraldi indicated the following corrections were required: • Hot water needed to measure between 105-120 degrees F. • Complete first aid kit • 30 day supply of Personal Protection Equipment (PPE) • Covered trash cans • Emergency food and water • Postings as required by the Department • Repair required throughout the facility Upon entry into the facility, the LPAs observed the Department Complaint Poster and Long Term Care Ombudsman (LTCO) poster at the front of the entrance. During today’s visit, the LPAs observed that the facility was in good repair. The licensee had fixed the door leading into Room #2, and fixed the door leading into the bathroom of Room #3. The auditory device for Room #1 is fixed, The ramp in the backyard was also repaired. At 10:35 a.m., water temperature measured at 116.6 degrees F. The LPAs observed that each trash can had an appropriate lid. There was an emergency supply of food and water. The applicants obtained a larger supply of Personal Protection Equipment (PPE). First aid kit was complete. Component 3 was completed during today’s visit. The physical plant has met regulatory requirements. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 13, 2023

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Emily Peraldi conducted a pre-licensing visit to the above noted facility. At 12:44 p.m., the LPA met with applicants . This a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is one story. At 1:10 p.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents and, one (1) of bedridden resident. The facility has four (4) resident bedrooms, all rooms are shared bedrooms except for Room #2 and Room #3. Resident bedroom #1 has a direct exit to the outside. Bedridden resident is allowed in resident bedroom #1. All resident rooms have beds, nightstands, lamps, chests of drawers, and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. Room # 5/ staff room is a designated staff room. All rooms were free of odors. All window screens were clean and maintained in good repair. There is an office area located near the dining area. There are cameras in the common areas. There are two (2) bathrooms in the facility. Resident bedroom #4 has a bathroom inside. The resident bathrooms have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found not within the range of 105*F and 120*F. At 1:16 p.m., the kitchen hot water temperature measured at 125.0*F. At 1:51 p.m., the bathroom hot water temperatures measured between 129.4*F. Resident and staff records are stored in a locked cabinet which is currently located near the dining area. Medications are centrally stored in a locked cabinet near the dining area. The first aid supplies were incomplete. Kitchen knives are stored in a locked drawer in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a cabinet located in the locked laundry hallway. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights will be maintained in hallways and passageways to nonprivate bathrooms. All ramps were not secured and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. At 1:22 p.m., the LPA observed a hole in the back-patio ramp. Alarms on all exterior doors were engaged at the time of visit and not functional. Room #1 auditory device was not functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility did not have emergency food and water supplies. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility smoke alarm system is hard wired. At 1:47 p.m., the smoke detector and carbon monoxide detectors were tested and functioned properly. The facility has a central entry point for symptom screening and temperature checks for staff and visitors. There is hand sanitizer available throughout the facility. There is a fire extinguisher near the kitchen area. It was fully charged and purchased on 03/22/2022. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the laundry closet. Extra incontinence supplies are stored in the laundry closet and in the garage. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout the facility. The emergency telephone numbers will be posted near the entrance of the facility. Other required postings will be posted near the entrance of the facility. The exterior passageways were clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. There is a gate with a knob mechanism that is not locked at the side of the house designated for an emergency exit. There are bodies of water on the premises at the present time. The swimming pool is fenced and locked. The garage is not accessible from the house; the garage door was locked. The following items must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to the LPA so that your application may be completed. - The facility needs to be clean and in good repair. The back patio ramp has a small hole. Room #3’s door to the restroom needs to be fixed. Room #2’s door needs to be fixed. - The hot water temperature for both the kitchen and bathrooms needs to read within the allowable range of 105*F to 120*F. - A complete first aid kit. - The facility needs to have emergency food and water. - Required postings need to be posted. - 30-day supply of Personal Protection Equipment (PPE). - Lid for bathroom trash can. This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.the state’s words, verbatim · CDSS document, Jan 30, 2023

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 5 Method: Telephone call with CAB COMP II Participants: Akhtar Roshanaeian, Applicant; Hripsime Tavitian, Administrator Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Nov 17, 2022