Country Rose Estate Memory Care

Allegation investigated: Lack of supervision resulted in resident eloping from facility and sustaining an injury

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Val Paraiso, Administrator, and informed him of the purpose of the visit. The LPA conducted staff/resident interviews, reviewed records, and took copies of pertinent documentation. A report was received alleging Resident One (R1) left the facility unsupervised on April 11, 2023 and was later found on the same day with a cut to their hand. The Administrator was interviewed and corroborated the allegation; he reported R1 did leave the facility without staff knowledge and was found approximately forty minutes later. Per staff, a third party contractor was providing maintenance services at the time and may have not properly locked the one exit gate on the property. Staff interviews reported R1 appeared to have sustained a fall due to observing dirt on their clothing and a cut on their hand. Interviews revealed R1 is not able to safely leave the facility unsupervised. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means the allegation is valid because the preponderance of the Substantiated evidence standard has been met. A citation will be issued. An exit interview was conducted; this report was reviewed with the Administrator and a copy was provided, along with appeal rights.the state’s words, verbatim · CDSS document, Apr 20, 2023 · control 18-AS-20230413101657

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 4, 2023

BASIC SERVICES: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met, as evidenced by: Based on interviews, the Licensee did not ensure R1 was supervised. The Administrator was interviewed & corroborated the allegation; he reported R1 did leave the facility without staff knowledge & was found approximately 40 mins later. Staff interviews reported R1 appeared to have sustained a fall due to observing dirt on their clothing & a cut on their hand.the state’s words, verbatim · CDSS document, Apr 20, 2023

Plan of correction: The Administrator stated an automatic door lock will be installed on the one exit gate on the property.

Type of visit: Required - 1 Year

On February 23, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced required annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Facility Manager introduced self, had temperature check by lead staff and signed in. LPA Mixson later spoke with Administrator via the telephone introduced self and stated the purpose of the visit. Present in the facility were ten residents and two caregivers. There are currently no positive cases of COVID-19 within the facility. All staff and all residents are vaccinated and have received boosters. LPA Mixson toured the facility with Facility Manager and made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities. The facility also has a plan in place to monitor resident's regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. LPA Mixson later discussed infection control practices and procedures with Facility Manager An exit interview was conducted and a copy of this report was given to Facility Manager.the state’s words, verbatim · CDSS document, Feb 23, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to follow up on a recent incident that occurred at the facility. LPA met with Administrator, Val Paraiso who was informed of the purpose of the visit. The regional office received a police report from an incident that occurred at the facility on 11/02/2022 between Resident (R1) and Resident 2 (R2). The police report from the San Marcos station details that the administrator called the police after R1 struck R2 with a cane. LPA reviewed resident records for Resident 1 (R1) and Resident 2 (R2) and took statements from the administrator. R1 is no longer residing at the facility and was the former roommate of R2. On 10/27/2022 R1 struck R2 on the shin, staff was able to separate the residents. The physician and responsible party were contacted, as R1 did not have a history of physical aggression. This was evidenced by R1's plan of care and preappraisal. On 11/2/2022 R1 was found by staff next to R2, verbalizing that they would strike R2. The administrator was able to separate R1 and removed the cane from R1. Staff called the police, who took a report, but were unable to 51/50 R1. R1's responsible party was looking for alternate placement after the incident as reported by the administrator. On 11/4/2022 staff was sitting next to R1 in the living room when R1 struck R2. Staff was able to separate the residents. On this date R1 was moved out of the facility by their responsible party. Based on the on records reviewed, and interview with administrator it was found that the facility was providing sufficient care and supervision for R1 and R2. No deficiencies were cited at the time of the visit An exit interview was conducted where this report was reviewed and provided to Administrator, Val Paraiso.the state’s words, verbatim · CDSS document, Nov 29, 2022

Allegation investigated: Staff do not treat client with dignity.

Licensing Program Analyst (LPA), Sabel Martinez, completed an unannounced complaint visit to conduct additional interviews and deliver findings regarding the mentioned allegation. The LPA was greeted by Caregiver. Yuri Ramirez Olvera, identified himself, and disclosed the purpose of the visit. Throughout the investigation, the LPA toured the facility, reviewed staff records, resident records, and conducted interviews with residents, staff, and outside sources. It was alleged staff did not treat a resident with dignity. Interviews with staff and residents revealed that on at least one occasion, Staff #1 (S1) was witnessed to be irritated and raising their voice at residents in care. Staff # 2 (S2) was described as argumentative and raising their voice at residents. Licensee was provided with Confidential Names Form, in order to identify S1 and S2. Interviews with residents corroborated perceiving that facility staff did not treat residents with dignity and staff were described as being “feisty” and "mean" with residents. Substantiated Based on the evidence gathered, there is a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation is Substantiated. This deficiency is documented on an LIC 9099D, and is cited in accordance with California Code of Regulations, Title 22. Administrator, Val Paraiso, was called, notified of the findings, and jointly formulated a Plan of Correction. An exit interview was conducted with Caregiver, Yuri Ramirez Olvera, to whom a copy of this report and Licensee's Rights (LIC 9058 01/16) were provided to.the state’s words, verbatim · CDSS document, Jul 26, 2022 · control 08-AS-20211207090521

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 26, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by Based on interviews, the Licensee did not ensure residents in care were treated with dignity which posed a potential health, safety, and Personal Rights risk to 3 of 14 persons in care.the state’s words, verbatim · CDSS document, Jul 26, 2022

Plan of correction: Administrator agreed to conduct in service training for all staff regarding Personal Rights of Residents in All facilities. Attendance sheet for this training will be submitted to the LPA by 8/26/2022.

Allegation investigated: Licensee does not meet general food requirements.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint visit to coduct additional interviews and deliver findings regarding the mentioned allegation. The LPA was greeted by Caregiver, Yuri Ramirez Olvera, identified himself, and disclosed the purpose of the visit. Throughout the investigation, the LPA toured the facility, reviewed staff records, resident records, and conducted interviews with residents, staff, and outside sources. It was alleged the licensee did not meet general food requirements. Interviews with staff revealed the facility has a staff designated to cook meals throughout the week. Meals prepared during the morning shift are then served by staff during each shift. Snacks are also available to the residents throughout the day. Interviews with residents corroborated the meals provided are of good quality, and options are often offered to residents. Unsubstantiated An interview with an outside source confirmed the facility to be well stocked with food items, and the residents expressing the food provided was adequate, on multiple visits. An ample amount, and variety of food was witnessed by the LPA on multiple visits conducted to the facility throughout the investigation. Contradicting interviews revealed staff are occasionally unable or unwilling to provide additional options, but residents are also able to obtain their own meals. Based on the evidence gathered throughout the investigation, there is not a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation is unsubstantiated. Administrator, Val Paraiso, was called and notified of the findings. An exit interview was conducted with Caregiver, Yuri Ramirez Olvera, to whom a copy of this report and Licensee's Rights (LIC 9058 01/16) were provided to.the state’s words, verbatim · CDSS document, Jul 26, 2022 · control 08-AS-20211207090521

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Sabel Martinez, conducted a complaint investigation visit in which an unrelated deficiency was noted. The LPA was greeted by Caregiver, Esmeralda Pancho, identified himself, and disclosed the purpose of the visit. Administrator, Val Paraiso, arrived during the visit. During today's visit, the following deficiency was noted: Caregiver S1 was observed to be working at the facility. Interviews with staff and administrator confirmed the S1 has been working at the facility for approximately over one months. A check of CCLD systems revealed that S1 does not have a criminal record clearance with the Department. Per California Code of Regulations, Title 22, the following deficiency is cited and listed on LIC 809-D. An immediate civil penalty of $500 was assessed today for Criminal Record Clearance violation on form LIC 421-BG. An exit interview was conducted with Administrator, Val Paraiso, to whom a copy of this report, LIC 421-BG, and Licensee's Rights (LIC 9058 01/16) were provided to.the state’s words, verbatim · CDSS document, Jun 21, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jun 21, 2022

87355 Criminal Records Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: This requirement was not met as evidenced by: Based on observations, interview and systems review, the licensee did not ensure S1 had a CA criminal record clearance prior to working in the licensed facility which posed an immediate safety risk to 14 of 14 clients in care.the state’s words, verbatim · CDSS document, Jun 21, 2022

Plan of correction: During the visit, Licensee agreed to remove unbackground cleared employee (S1). The LPA witnessed S1 leaving the facility. Licensee agreed not to have staff return to work until S1 has received clearance from the Department.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required 1 - Year Visit. LPA Martinez was greeted by Caregiver Becky Bonamici, identified himself, and discussed the purpose of the visit. Administrator, Val Paraiso, arrived during the visit. LPA Martinez conducted a tour with Caregiver and Administrator. In accordance with the Department’s Infection Control program, LPA Martinez provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808). LPA Martinez observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit. An exit interview was conducted with Administrator Val Paraiso, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A read receipt email confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Jan 31, 2022