Country Place Assisted Living

Type of visit: Case Management - Other

On 11/08/23 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct a case management visit pertaining to an incident which occurred on 10/31/23 wherein 41 residents were left unsupervised during a fire alarm at 4AM set off by a resident. Fire responders confirmed with LPA that they observed no staff was present inside the facility when they deactivated the fire alarm at 5AM on 10/31/23. An immediate civil penalty of $500 is being assessed for absence of supervision on 10/31/23 which is in violation of Title 22 Section 87415 (a)(2) Night Supervision. Exit interview conducted, Appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Nov 8, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87415(a)(5) · Plan of correction due date: Nov 8, 2023

In facilities required to have a signal system, specified in Section 87303, Maintenance Operation, at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake. This requirement was not met as evidenced by absence of supervision on 10/31/23 which posed an immediate health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Nov 8, 2023

Plan of correction: Immediate civil penalty of $500 is assessed today for absence of supervsion. Administrator corrected deficiency on 11/01/23. S1 was terminated due to work negligence and S2 suspended without pay until retrained on proper care and supervision of residents.

Type of visit: Required - 1 Year

On11/08/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, additional face masks and hand sanitizer were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand washing signs were observed posted in common areas. Facility has a 30-day supply of PPEs, paper, medications locked in medication room cabinets. Comfortable temperature was observed at 75 deg F per thermostat reading. Hot water temperature was measured at 118 deg F. Fire extinguishers were last inspected on 12/01/22 and observed fully charged. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. LPA also conducted 3 staff and 3 resident interviews during visit. The following deficiency were observed during inspection: Ants in room #7 Open trash bins in residents' rooms & bathrooms Continued on next page, LIC 809-C Updated copies of the following documents were obtained from administrator:  LIC500- Personnel Report  Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 8, 2023

Allegation investigated: Facility is unsanitary

On 11/01/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM1) to deliver the finding of above allegations. LPA explained the purpose of the visit with ADM1. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, physicians’ orders, showering schedules, housekeeping schedules, incident reports. Allegation: Facility is unsanitary Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Continued on next page, LIC 9099-C Substantiated Allegation: Facility is unsanitary Investigation Finding: Substantiated Continuation Staff (ADM1) confirmed with LPA that the main couch in the living room had urine/feces stains due to frequent usage by residents. LPA observed living room couch had urine stains on fabric during visit on 07/14/23. ADM stated that in August 2023 that she purchased a cleaning machine that staff use regularly to remove the stains and odors from the faux upholstered and suede covered living room couches. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) facility is unsanitary was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Facility is odiferous Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. On 07/14/23 at 10:30AM, LPA toured the facility with staff (S1) including but not limited to the main dining area, kitchen, storage areas, living room, common hallways, bedrooms, bathrooms and activity room. LPA observed no odiferous odors from the areas inspected. LPA also observed S3 cleaning the common hallways while touring with S1. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility is odiferous and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility is odiferous is unsubstantiated. Allegation: Staff do not accord residents with dignity while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff (S1, S2) who denied not treating residents with dignity while providing care and supervision. Staff (S1, S2) stated they do not tell residents to “go away” or “go sit down” when they need help. During visit. LPA observed staff assisted residents with their prescribed medications, meals without yelling or screaming at them and responded to their requests for help in a friendly manner. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not accord residents with dignity while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not accord residents with dignity while in care is unsubstantiated. Continued on next page, LIC 9099-C pg2 Allegation: Staff do not accord residents with privacy while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff (ADM1,S2) who stated that most residents know their prescribed medication schedules and would go to the medication room daily to take their prescribed or over the counter medications. S2 stated staff rarely dispense medications in front of other residents in the dining room. LPA interviewed residents (R1, R2, R3, R4) who confirmed they take their daily medications from staff inside the medication room. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not accord residents with privacy while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not accord residents with privacy while in care is unsubstantiated. Allegation: Staff do not ensure that residents have the ability to request assistance when needed Investigation Finding: Unsubstantiated During investigation, LPA toured the facility with staff (ADM1) including but not limited to the main dining, kitchen, living room, bedrooms, bathrooms, activity room. LPA observed each bedroom has an emergency call/pull cord situated against the wall next to the residents’ bed. ADM stated residents can pull the cord when necessary to alert staff for assistance. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not ensure that residents have the ability to request assistance when needed and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not ensure that residents have the ability to request assistance when needed is unsubstantiated. Continued on next page, LIC 9099-C pg 3 Allegation: Facility does not have sufficient amount of staff to meet residents’ care needs Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed staff records. Review of personnel records dated 07/2023 showed the facility had sufficient staffing including on call staff available for scheduled AM, PM and NOC shifts to provide care and supervision to residents in care. LPA interviewed residents (R1, R2, R3, R4) who stated that staff met their care needs. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility does not have a sufficient amount of staff to meet residents’ care needs and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility does not have a sufficient amount of staff to meet residents’ care needs is unsubstantiated. Allegation: Staff do not ensure that residents get a sufficient quantity of food while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed scheduled meal deliveries and records. Staff (S1) stated they order and receive deliveries of groceries (variety of meats, breads, fresh fruits, vegetables, cereals, eggs, canned goods, potatoes, pancakes) every week. If residents do not like the food, they are given sandwiches that they can eat plus 2 snacks per day. S1 stated there are a few residents that need to follow a special diet as prescribed by their doctors to control their diabetes, high blood pressure, mechanical soft diet for some with digestive issues. Residents on a regular diet are given second helpings upon request. Staff serve residents breakfast, lunch, dinner, snacks in between meals and drinks daily. LPA observed staff preparing snacks and drinks for residents during visit. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not ensure that residents get a sufficient quantity of food while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not ensure that residents get a sufficient quantity of food while in care is unsubstantiated. Continued on next page, LIC 9099-C pg 4 Allegation: Staff did not ensure that resident’s diapering needs were met while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. On 07/14/23 at 11:30AM, LPA interviewed resident (R1) who stated that staff helped her with changing her diapers daily. During visit, LPA interviewed other residents (R2, R3, R4) who stated that staff assisted them with their activities of daily living such as showering, toileting, grooming, dressing, changing diapers, medications and meals. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that resident’s diapering needs were met while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure that resident’s diapering needs were met while in care is unsubstantiated. Allegation: Staff did not ensure that resident’s showering needs were met while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of resident’s (R1) functional assessment dated 07/01/23 showed R1 required total assistance with bathing (helping residentl in and out of the tub, complete washing and drying of the body). During visit, LPA interviewed R1 who stated that staff assists her with bathing, hygiene, toileting, dressing, eating, medications, changing diapers, telephone use and transportation to outings and shopping. LPA observed R1 was clean and odor free. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that resident’s showering needs were met while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure that resident’s showering needs were met while in care is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 15-AS-20230705153014

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 1, 2023

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 was not met as evidenced by unsanitary furniture which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: Deficiency corrected August 2023. Administrator purchased new cleaning machine to remove the stains and odors from the faux and suede upholstered couches in the living room area to ensure the furnitures are sanitary in compliance with Title 22 Section 87303 (a).

Allegation investigated: Residents were left unsupervised while in care

On 11/01/23 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit , met with administrator (ADM1) and delivered investigation finding to ADM. LPA explained the purpose of the visit with ADM1. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, emergency/disaster plans, incident report. Continued on next page, LIC 9099-C Substantiated Allegation: Residents were left unsupervised while in care Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident records. Witness (W1) confirmed with LPA that on 10/31/23 at 4AM the fire department responded to a fire alarm which has been activated at the facility for 30 minutes. When fire responders arrived, they opened the front gate with a key and a resident opened the front entrance of the facility. Fire responders stated no staff was awake and on hand to actively supervise the residents. W1 stated they forced opened the office and called the administrator (ADM) who rushed to the facility and arrived around 5:30AM. Staff (S1, S2) were found by police and fire responders sleeping in their cars at the parking lot. Review of incident report dated 10/31/23 confirmed that staff (S1, S2) were asleep inside their cars at the parking lot while on night shift and were not inside the facility when the fire alarm was set off by a resident at 4AM. FIre alarm was blaring at the facility for 30 minutes and was deactivated by fire responders when they arrived at 5AM. ADM stated all residents were safe and no injuries were observed. ADM1 stated S1 was terminated 10/31/23 due to negligence and S2 was placed on unpaid leave while facility schedules mandatory in-service staff retraining on proper care and supervision of residents while on duty. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that residents were left unsupervised while in care was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 15-AS-20231031160632

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87415(a)(2) · Plan of correction due date: Nov 10, 2023

In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes This requirement was not met as evidenced by unsupervised residents during a fire alarm which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: By POC due date, administrator agreed to complete and submit to CCL staff re-training certifications regarding night shift supervision (one staff awake & on duty with one staff on call capable to respond within 10 minutes) in compliance with Title 22 Section 87415 (a)(2).

Type of visit: Case Management - Health Checks

On 06/14/23 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced health and safety check case management visit. LPA explained the purpose of the visit with administrator (ADM). During the health and safety check, ADM confirmed with LPA that resident (R1) is adjusting well in the community since admittance on 06/06/23. ADM stated R1 started playing domino's and cards with two other residents in the activities room. LPA observed R1 comfortably resting inside his bedroom and that there is no imminent health or safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 14, 2023

Allegation investigated: Facility staff did not properly manage resident's medication

On 06/01/23 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit and met with administrator (ADM). LPA conducted interviews & record reviews and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM. Allegation: Staff did not properly manage resident’s medication Investigation Finding: Substantiated During investigation, LPA confirmed with staff (S1) that resident’s (R1) prescription medications were not refilled in a timely manner resulting in R1 being without medication for 6 days. Witness (W1) also confirmed that R1’s prescription medications were not timely refilled for administration on 04/21/23 to 04/27/23. Continued on next page, LIC 9099-C Substantiated Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not properly manage resident’s medications was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report providedthe state’s words, verbatim · CDSS document, Jun 1, 2023 · control 15-AS-20230522162104

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jun 23, 2023

Once ordered by the physician the medication is given according to the physician's directions… This requirement was not met as evidenced by staff failing to get timely refills for resident which posed a potential health & safety risk to resident in carethe state’s words, verbatim · CDSS document, Jun 1, 2023

Plan of correction: By POC due date, Administrator agreed to submit to CCL written self-certification that staff has read, understood and will comply with Title 22 Section 87465 regarding incident Medical and Dental care of residents.

Type of visit: Case Management - Health Checks

On 12/07/22 at 1PM, while at the facility for another reason, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving an incident report received 12/06/22. During the health and safety check, LPA observed a total of 7 staff members and 33 residents at the facility. LPA toured facility with maintenance director, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 7, 2022

Type of visit: Case Management - Other

On 12/07/22 at 1:45PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit regarding an incident report faxed to CCL on 12/06/22. LPA explained the purpose of the visit with the Care Coordinator (CC). CC stated resident (R1) was first admitted at the facility on 12/10/2012. CC stated R1 was verbal, ambulatory, independent and did not display any signs of pain or discomfort. Staff stated R1 passed away on 12/06/22 at approximately 7:20AM in her sleep. Staff called 911 to report the death. Police arrived 12/06/22 and conducted a welfare check. R1's body was released by the coroner's office the same day. Administrator requested for a copy of R1's death certificate and will submit it to CCLD once available. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 7, 2022

Type of visit: Required - 1 Year

On 12/07/22 at 1:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an infection control annual inspection and explained the purpose of the visit with Care Coordinator (CC). LPA observed 7 staff wearing face masks and 14 residents enjoying the nice weather outdoor patio area. Facility has a mitigation plan in place to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. Routine symptom checks are done for universal screening with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. COVID-19 signs are posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since February 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 76 degrees Fahrenheit. Adequate supplies of PPE were also observed stored in the various locations (storage area, med room and office). Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 12/08/22: · LIC500- Personnel Report · LIC308- Designation of Facility Responsibility · LIC610E- Emergency/Disaster Plan/Infection Control Plans · Evidence of Liability Insurance No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.the state’s words, verbatim · CDSS document, Dec 7, 2022

Allegation investigated: Staff is not provided adequate PPE

On 09/13/22 at 10:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with staff (S1) and administrator (ADM). LPA explained the purpose of the visit with S1 and administrator. During visit, LPA observed S1 wearing N95 face mask and face shield. LPA also observed 4 other staff wearing N95 face masks. S1 showed LPA sufficient supplies of PPEs (face shields, gowns, gloves, disposable shoe covers, N95 face masks, gloves) stored in the medication room cabinets. Local Public Health conducted a site visit on 08/30/22. ADM stated staff implemented LPH recommendations the same day to ensure mitigation of COVID infection at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. Nothe state’s words, verbatim · CDSS document, Sep 13, 2022 · control 15-AS-20220912104729

Allegation investigated: Staff failed to provide adequate supervision resulting in altercation between residents Resident was injured while in care

On 06/30/22 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator. Allegation: Staff failed to provide adequate supervision resulting in altercation between residents Investigation Finding: SUBSTANTIATED Based on interviews and record reviews, incident report dated 05/08/20 show that resident (R1) was arguing with another resident (R2) at the facility over a chair on 05/05/20. R2 pushed R1 who fell on her behind. Staff (S2) reported the incident to another staff (S3) who called 911. R1 was sent to the hospital for evaluation & treatment. S3 contacted R1’s authorized representative and facility administrator about the incident. Continued on next page, LIC 9099-C Substantiated R1 was diagnosed at the hospital with a hip fracture and later sent to a skilled nursing facility for rehabilitation. The preponderance of evidence has been met. Therefore, the allegation is substantiated. Allegation: Resident was injured while in care Investigation Finding: SUBSTANTIATED Review of incident report dated 05/05/20 show resident (R1) suffered a hip fracture at the facility early May 2020 requiring hospitalization and rehabilitation. The preponderance of evidence has been met. Therefore, the allegation is substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Jun 30, 2022 · control 15-AS-20200519141432

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Jul 29, 2022

All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance. Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by staff failing to redirect residents which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2022

Plan of correction: By POC due date, Administrator agreed to submit to CCLD a copy of in-service staff retraining in providing proper care and supervision to residents in care at all times.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jun 30, 2022

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608 This requirement was not met as evidenced by resident sustaining injury while in care which posed a potential health & safety risk to resident in carethe state’s words, verbatim · CDSS document, Jun 30, 2022

Plan of correction: Administrator corrected deficiency during visit. Updated personnel records show sufficient staff to meet residents’ needs.

Allegation investigated: Head lice present at the facility

On 06/30/22 at 12:24PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator, gathered information relevant to the allegations and delivered investigation findings to administrator. LPA explained the purpose of the visit with administrator. Allegation: Head lice present at the facility Investigation Finding: SUBSTANTIATED Based on interview and record reviews, administrator confirmed with LPA that resident (R1) had head and body lice infestation at the facility. After visit summary report dated 06/22/22 from the hospital also show R1 was seen in the ER for head and body lice. R1 was treated and discharged back to the facility with instructions on how to eliminate the lice with medications. The preponderance of evidence has been met. Therefore, this allegation is substantiated. Continued on next page, LIC9099-C Substantiated Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Jun 30, 2022 · control 15-AS-20220622082854

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b) · Plan of correction due date: Jul 29, 2022

The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement was not met as evidenced by resident's change in condition which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Jun 30, 2022

Plan of correction: By POC due date, Administrator agreed to submit to CCLD copy of staff retraining in timely addressing resident's change in condition to ensure their health & safety needs are met.

Allegation investigated: Facility staff are not accepting resident back to the facility

On 12/31/21 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the finding of above allegation. LPA explained the purpose of the visit with care coordinator (S1). LPA spoke to administrator (ADM) on the phone and explained the purpose of the visit to S1 and ADM who authorized S1 to act on her behalf and sign the reports. Allegation: Facility staff are not accepting resident back to the facility Investigation Finding: SUBSTANTIATED Based on interviews and record reviews, resident (R1) was admitted to a rehabilitation center on 05/12/2020 after sustaining a fall at the facility resulting in a hip injury. R1’s SNF face sheet lists R1 as her own responsible party. Continued on next page, LIC 9099-C Substantiated On 05/21/2020, the rehabilitation center called the facility to arrange for R1’s return to the facility. The staff who answered the call told the rehab center to call back the next day because facility will not be accepting R1 back to the facility. The rehab center was not informed of R1’s relationship with the department of Public Health, Placement Authorization and Utilization management, Transitions-Placement Team until 4 days later. The preponderance of evidence has been met. Therefore, the allegation is substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Dec 31, 2021 · control 15-AS-20200529093816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(b)(1) · Plan of correction due date: Dec 31, 2021

Personal Rights of Residents in all facilities (b) All residents in all residential care facilities for the elderly shall be protected from all of the actions specified in this subsection. A licensee or facility staff may not take any of the following actions, which also includes taking these actions wholly or partially on the basis of the actual or perceived sexual orientation, gender identity, gender expression, or human immunodeficiency virus (HIV) status, of a resident: (1) Deny admission to a facility, transfer or refuse to transfer a resident within the facility or to another facility, or discharge or evict a resident from a facility.the state’s words, verbatim · CDSS document, Dec 31, 2021

Plan of correction: Administrator corrected deficiency on 06/10/2020 where resident (R1) returned back to the facility from the rehabilitation center.

Allegation investigated: Insufficient staff to meet the needs of the residents Facility is not clean

On 12/31/21 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the finding of above allegation. LPA explained the purpose of the visit with care coordinator (S1). LPA spoke to administrator (ADM) on the phone and explained the purpose of the visit to S1 and ADM who authorized S1 to act on her behalf and sign the reports. Allegation: Insufficient staff to meet the needs of the residents Investigation Finding: UNSUBSTANTIATED During investigation, LPA observed sufficient staffing on10/26/2020 (2 caregivers/med tech, 2 housekeepers, 1 dietary supervisor, 2 kitchen aides and 1 administrator) at the facility providing care and supervision to 46 residents. Residents were observed calm and comfortable in their surroundings. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Facility is not clean Investigation Finding: UNSUBSTANTIATED During investigation, LPA observed several COVID-19 signages, disinfectants, sanitizers in the front/main entrance, hallways and common areas. LPA toured 4 residents' units with bathrooms. LPA observed residents' floors, walls and bathrooms/toilets appeared to be clean and in good repair. LPA observed residents comfortably resting inside their apartment. LPA did not observe any signs of smeared fecal matter on the walls or floors. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Dec 31, 2021 · control 15-AS-20201014123817

Allegation investigated: Staff are falsifying COVID vaccination records

On 11/24/21 at 2:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, gathered information relevant to the allegation and delivered the investigation finding to staff (S1) and administrator (ADM). LPA explained the purpose of the visit with S1 and ADM. S1 gave a random sampling of COVID-19 vaccination cards (8) to LPA during visit. Based on record reviews and observation, each card contained the product name/Manufacturer lot number, date of 1st dose/2nd dose and clinic site. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, Nov 24, 2021 · control 15-AS-20211117110613

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 11/24/21 at 3:20PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with staff (S1). LPA observed 4 staff wearing face masks during visit. Facility has a completed mitigation plan in place dated 01/29/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Continued on next page LIC 809-C Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since February 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed locked inside the storage room. Facility room temperature was maintained at 74 degrees Fahrenheit. Administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 11/29/2021: · LIC500- Personnel Report · LIC308- Designation of Facility Responsibility · LIC610E- Emergency/Disaster Plan · Evidence of Liability Insurance No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.the state’s words, verbatim · CDSS document, Nov 24, 2021

Type of visit: Case Management - Other

On 09/21/21 at 11:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit and met with manager on duty (MOD). LPA spoke with administrator (ADM) on the phone who authorized MOD to act on her behalf and sign the report. LPA explained the purpose of the visit to ADM and MOD. ADM stated that the administrator for this facility is S1, who is temporarily on maternity leave. LPA discussed with ADM that she cannot be the administrator for 2 residential care facilities for the elderly (RCFE) located in two different regions. ADM understood and stated she will comply with this requirement.ADM will email a copy of facility's current Personnel Record (LIC 500) to LPA today, September 21, 2021. Exit interview conducted and a copy of this report provided to MOD.the state’s words, verbatim · CDSS document, Sep 21, 2021