Desert Hills Memory Care Center

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Facility management retaliated against staff member Facility is not following their plan of operation

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Shannon Moore and explained the reason for the visit. The investigation consisted of the following: On 1/30/24 LPA Ross conducted initial investigation visit. On 12/1/25 LPA Flores requested pertaining documents. On 12/3/25 LPA Flores conducted interviews with 6 residents and 6 staff. On 12/4/25 LPA Flores delivered findings. The investigation revealed the following: Regarding allegation: Facility management retaliated against staff #1(S1). It is alleged licensee retaliated against staff for bringing up concerns. . Interviews with residents revealed residents did not have concerns about the staff. Interviews with 6 staff revealed 6 out of 6 staff stated management has not retaliated against the staff. 1 out of the 6 stated there was a staff in management before that was difficult to communicate with and 1 out of the 6 staff mentioned they rather not bring up issues to management. (CONTINUED ON LIC 9099C) Unsubstantiated Per Executive Director, the management team had concerns that had been brought up to them regarding communication from S1 towards others. However, it was the staff that resigned and was not fired. Per documents reviewed S1 provided a resignation letter to the facility on 1/3/24 and their last day of employment was 1/24/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility does not follow their plan of operation. It is alleged facility did not have a plan to provide training to staff to deal with residents that have behaviors. Interviews conducted with residents revealed facility’s staff provide adequate care to the residents. Interviews with staff revealed staff receive 40 hours of initial training and throughout the year they complete their additional training yearly, including behavioral response training. Documents reviewed revealed in 11/7/24, 12/3/24, and 12/18/24, staff received training in the following topics: Psychosocial Needs of the Elderly, Takes a Village Other Side of the Mirror, Positive Therapeutic Interventions and Activities. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Shannon Moore and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 18-AS-20240126082906

Allegation investigated: Staff are not addressing an outbreak of scabies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Shannon Moore and explained the reason for the visit. The investigation consisted of the following: On 7/10/24 LPAs Martinez and V. Flores conducted initial investigation visit. On 12/1/25 LPA Flores contacted administrator and requested pertaining documents and attempted to contact Riverside Department of Public Health (RDPH). On 12/1/25 and 12/2/25 LPA Flores attempted to contact RDPH. LPA On 12/3/25 LPA Flores interviewed 6 residents and 6 staff, and reviewed 6 resident files. On 12/4/25 LPA delivered findings. The investigation revealed the following: Regarding allegation: Staff are not addressing an outbreak of scabies. It is alleged residents at the facility have scabies. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews conducted with residents revealed 4 out of 6 residents were unable to answer due to cognitive skills. 2 out of 6 residents stated staff provide skin care for skin related issues. Interviews with staff revealed facility did not have a scabies outbreak. According to the staff there are residents that have skin conditions. However, they are receiving treatment per the physician recommendations and residents have not been diagnosed with scabies. Document review revealed on August 8/20/24 Resident #1 was prescribed scabies treatment, on 8/20/24 Resident #2 was prescribed scabies treatment, and on 8/23/24 Resident #3 had scabies treatment active on medication list. On 12/4/25 LPA Flores spoke to Assistant Nurse Manager at Riverside University Public Health who stated there are no records of facility reporting a scabies outbreak. Although the facility may have not reported the cases. The facility was following physician's recommendations to treat the symptoms. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Shannon Moore and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 18-AS-20240702131513

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff did not keep facility free of pests

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Shannon Moore and explained the reason for the visit. The investigation consisted of the following: On 8/20/24 LPAs Jeon, Castillo and Sabarias conducted an initial complaint investigation, conducted a tour of the facility, interviewed 3 staff and 2 residents, and requested pertaining documents. On 10/25/24 LPA Jeon conducted a subsequent visit and interviewed 7 residents. On 12/1/25 LPA Flores requested pertaining documents for resident #1(R1). On 12/3/25 LPA Flores conducted a tour of the facility, interviewed 6 staff, and delivered findings. The investigation revealed the following: Regarding allegation: Staff did not keep facility free of pest. It is alleged facility has bedbug infestation. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with residents revealed 7 out of 9 interviewed revealed residents did not have bug bites in their skin, have not observed bed bugs at the facility, and stated bed sheets are change at least once a week. 1 out of 9 residents had skin lesions for which treatment was being applied and 1 out of 9 residents refused to be interviewed. Interviews with staff revealed staff have not observed bed bugs in the facility. Documents reviewed revealed facility received monthly pest control services between May and September of 2024. No notes on observations or services for bed bugs were noted. R1's notes note treatment for skin condition on 8/20/24. On 8/20/24 LPA Jeon observed facility clean, organized, and observed one resident with skin lesions. On 12/3/25 LPA Flores tour 5 resident rooms and observed their bed and bedding supplies, LPA did not observe bed bugs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Shannon Moore and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 3, 2025 · control 18-AS-20240812155053

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff are not mitigating the spread of infectious outbreaks in the facility Staff do not ensure sufficient supplies are available Staff are drinking on the facility premises

*This is a corrected version and supersedes report dated: 11/19/25 to correct finding noted on report from Needs Further to Unsubstantiated.* Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Shannon Moore and explained the reason for the visit. The investigation consisted of the following: On 8/22/23 LPA Martinez conducted an initial complaint investigation visit and requested the pertinent documents. On 12/18/23 LPA Martinez conducted a subsequent complaint visit. On 1/23/24 LPA Martinez conducted a subsequent visit and interviewed residents. On 11/7/25 LPA Flores contacted administrator and requested physician’s reports, face sheets, incident reports for 9 residents. On 11/8/25 LPA Flores interviewed 3 staff over the phone. On 11/10/25 LPA Flores contacted Riverside Department of Public Health. (CONTINUED ON LIC 9099C) Unsubstantiated On 11/17/25 LPA Flores interviewed 2 staff over the phone and requested medication sheets for July-September 2023, for 9 residents. On 11/19/25 LPA Flores conducted a subsequent visit and interviewed 4 residents. The investigation revealed the following: Regarding allegation: Staff are not mitigating the spread of infectious outbreaks in the facility. It is alleged several residents have an infectious skin disease and facility administration is not providing proper mitigation. Interviews with staff revealed upon an infection outbreak staff follow their protocol. Per administrator and wellness director upon questionable scabies cases, residents may be sent to obtain a diagnosis with physician, the resident is isolated, linens are clean daily, treatment is given as directed, and staff are to use proper PPE which includes gloves and gown when providing care. Interviews with staff confirmed the facility’s protocol described by administrator during a scabies outbreak. Interviews with residents revealed staff have been observed using preventive measures to prevent the spread of an infectious disease. Document review revealed between July-August of 2023 there were 7 residents receiving treatment for scabies. Although there were several receiving treatment there is not enough evidence to say the facility had a scabies outbreak and staff were not using preventing measurements to prevent the spread. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff do not ensure sufficient supplies are available. It is alleged PPE supplies are not being provided for staff to provide care to residents with infection disease. Interviews with residents revealed staff have been observed using gloves while providing care and when necessary other PPE supplies. Interviews with staff revealed facility has not run out of PPE supplies during an outbreak. During today’s visit LPA reviewed PPE supplies and observed mask, gloves, some gowns. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. (CONTINUED ON LIC 9099C) Regarding allegation: Staff are drinking on the facility’s premises. It is alleged management team is consuming alcohol in the premises. Interviews with residents revealed staff have not been observed under the influence of alcohol. Interviews with staff revealed staff have not consumed alcoholic beverages during holiday parties. LPA did not observed or smell staff under the influence during the visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Shannon Moore and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 21, 2025 · control 18-AS-20230814115217

Allegation investigated: Resident sustained injuries while in care Staff handled resident in a rough manner Staff are overdosing resident Staff left resident in soiled clothing for extended period of time Staff did not safeguard residents personal belongings

On May 06, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and met with Licensee, Shannon Moore. LPA explained the reason for the visit was to provide findings for the complaint investigation. On March 21, 2022, Community Care Licensing received a complaint alleging, Resident sustained injuries while in care,Staff handled resident in a rough manner, Staff are overdosing resident, Staff left resident in soiled clothing for extended period of time, and staff did not safeguarded residents personal belongings. During the investigation LPA conducted interviews, record reviews, and made observations. Regarding the allegation Resident sustained injuries while in care, it was reported R1 sustained a serious knee injury. It was also reported that R1’s knee was swollen and R1 was unable to move it. Information obtained from interview with Executive Director, Chantelle Hudson advised R1 had no falls and injuries reported during placement. Executive Director indicated R1 was placed for 30-day respite care. Interviews with additional staff indicated there were no bruises observed. Additional information obtained from interviews with staff stated R1 did not have any falls due to R1 being “total assist” with a Hoyer lift for transferring. It was further stated a hospice nurse would visit the facility two to three times per week and a representative from a home health agency would come once or twice a week. Additional information obtained from interviews with hospice nurse stated body checks of R1 was conducted and no bruises were observed. Interviews with additional residents indicated there no concerns with obtaining any injuries while in care. LPA’s record review confirmed there were no new injuries obtained during R1’s placement. Records reviewed included a “Daily Skin Checks” log, and Hospice Nurse Sign In Sheet. The review of records confirmed the last skin check was conducted with Hospice Nurse and R1’s Responsible Party and was signed off that there were no concerns. Unsubstantiated Regarding the allegation Staff handled resident in a rough manner, it was reported two unidentified women smashed R1 into the wall and caused a knee injury. Administrator denied this allegation. Information obtained from interview with Administrator advised R1 did not advise that facility staff handled R1 in a rough manner. Additionally, Administrator stated R1 was aggressive and abrasive towards staff. Information obtained from staff interviews denied they were rough with R1 or observed other staff being rough with R1. Information obtained from interviews with residents indicated there has not been a time when staff has handled them in a rough manner and they have not seen any staff miss handle any other residents. A review of the records did not document there were any disciplinary actions regarding personal rights violations. Regarding the allegation staff are overdosing resident, it was reported R1 had a prescription of a specific medication since 2021 and only 60 pills were given over the course of several months, but the facility managed to give R1 60 pills in a matter of 15-30 days. Wellness Director, Shannon Moore denied this allegation and stated that the medication was distributed as prescribed by R1’s Physician’s orders. Information obtained from interviews with staff stated medication was given as ordered. Staff also stated that R1’s medications were not re-evaluated during the 30-day respite stay. Information obtained from interview with Hospice Nurse indicated there were no concerns brought to the attention of the hospice team regarding R1’s medication. A review of the records, which included R1’s Medication Administration Record (MAR), and R1’s centrally stored medication report, indicated that the medication was provided to R1 as prescribed. Regarding the allegation staff left resident in soiled clothing for extended period of time, it was reported that R1 was observed to be covered in feces. Executive Director denied this allegation and stated R1 was never left in soiled clothing for extended periods of time. Additional information indicated R1 was able to communicate and share when they needed to be changed. Information obtained from interview with additional staff indicated R1 was not ever covered in feces or left in soiled clothing for an extended amount of time. Staff advised the facility has a changing schedule, which would occur every 1.5 to 2 hours. Information obtained from interview with Hospice Nurse stated R1 was not observed to be covered in feces and did not mention to staff that there were any issues or concerns with linen or garments being changed in timely manner. Regarding the allegation staff did not safeguard resident’s personal belongings. It was reported R1’s necklace was missing for 72 hours. Information obtained from interview with Wellness Director stated the necklace was reported missing, but was found. It was advised that R1’s responsible party received and signed for the items. No further details were provided regarding where the necklace located. LPA’s review of Resident Personal Property and Valuables Report, along with a photo copy, and signed document indicating the item was removed from the facility. Interviews with additional staff corroborated the information. Interviews with additional residents indicated there are no concerns with their items being safeguarded. Based on interviews, record reviews, and observations, regarding the allegations that resident sustained injuries while in care, staff handled resident in a rough manner, staff are overdosing resident, staff left resident in soiled clothing for extended period of time, and staff did not safeguard resident’s personal belongings are unsubstantiated. Although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur due to the inability to interview R1. An exit interview was conducted. A copy of this report was provided to Administrator, Shannon Moore.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 18-AS-20220321154449

Allegation investigated: Staff do not ensure that resident's dental needs are being met. Resident's room is in disrepair. Staff are preventing resident from leaving the facility.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Executive Director, Shannon Moore, who was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented conducted a walk through, and conducted records review. It was alleged that “Staff are preventing resident from leaving the facility.” It was alleged that Resident #1 (R1) had legally revoked their Power of Attorney (POA) and became self- responsible on 01/16/2024. It was alleged that R1 was not allowed to leave the facility. Unsubstantiated LPA attempted to conduct interview with R1, however they were unavailable. LPA conducted interviews with residents (2) residents who resided at the facility when the complaint was received. (1) of (2) residents revealed they recalled R1 but did not know if staff was preventing R1 from leaving the facility. Department staff conducted (2) administrative staff interviews which revealed R1 provided a copy of their new POA documents and moved out the same day 01/29/2024. R1’s file revealed the facility received a faxed letter from R1’s attorney dated 01/16/2024. Facility sign out sheets and SOC341 for R1 revealed that on 01/29/2024 R1’s attorney came to visit R1, and R1 moved out of the facility the same day. Therefore based on interviews and records review the allegation that R1 was not allowed to leave the facility is unsubstantiated. It was alleged “Staff do not ensure that resident's dental needs are being met.” It was alleged that Resident #1 (R1) was denied medical care to see a dentist for a broken tooth since May of 2023 by the facility. The Department received a photo showing a chipped tooth which allegedly belonged to R1. LPA attempted to conduct interview with R1, however they were unavailable. LPA conducted interviews with (2) residents who resided at the facility when the complaint was received. (1) of (2) resident’s recalled R1 and revealed they did not recall R1 mentioning they were being denied medical care. (2) of (2) residents revealed staff assists them in making doctor’s appointments when needed. Department staff conducted (4) staff interviews. (3) of (4) staff revealed no staff refused to make medical or dental appointments for R1. (3) of (4) staff revealed R1 would refuse to attend doctor’s appointments and refused to be taken out for medical treatment. R1’s file revealed R1 attended a dental appointment on 10/02/2023 for a broken tooth which revealed R1 refused care. Therefore based on interviews and records review the allegation that R1 was denied dental care while at the facility is unsubstantiated. It was alleged “Resident's room is in disrepair.” It was alleged that R1’s room had a hole in the ceiling for (1) month in January 2024 and was not repaired. It was alleged the hole was observed on 01/05/2024 and again on 01/17/2024, with a plastic sheet over it. The Department received a photo of a hole in dry wall which was covered by a taped plastic sheet. It was alleged this was located in R1's room ceiling. LPA attempted to conduct interview with R1, however they were unavailable. LPA conducted interviews with (2) residents who resided at the facility when the complaint was received. (2) of (2) residents confirmed the facility ceiling had a leak which was repaired promptly. (1) of (2) residents revealed they would visit R1 in their room and revealed R1’s ceiling leak was repaired promptly. Department staff conducted (6) staff interviews. (5) of (6) staff revealed R1’s room had a leak and R1 and their roommate were provided an alternate room, but R1 refused to move out of the room. (4) of (6) staff revealed R1’s leak was repaired promptly, however R1 refused for staff repair the hole in the ceiling. Facility records revealed on 11/16/2023 a roofing company was hired for repair. (1) administrative staff revealed repairs continued until January of 2024, and R1's ceiling hole was able to be repaired when R1 moved out. Therefore, based on interviews and records review the allegation that R1’s room was in disrepair is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 19, 2025 · control 18-AS-20240122095107

Allegation investigated: Staff did not prevent an unknown individual access to the facility resulting in a resident being physically attacked while in care.

On 04/24/25 Licensing Program Analysts (LPA)s Abdoualye Zerbo and Javina George made an unannounced visit to the facility to commence a complaint investigation for the allegation noted above. LPA met with Lavina Dubose, Memory Care Director and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, and the investigation consisted of observations, interviews and record review. On 04/16/25 Community Care Licensing received a complaint alleging staff did not prevent an unknown individual access to the facility resulting in a resident being physically attacked while in care. Per interview with Executive Director Shannon Moore, there has not been any incidences as alleged to have occurred with individuals outside of the facility being granted access to the facility and attacking any residents in care. Per a file review the facility is a secured perimeter and requires a door code to be granted entry to each buidling on the premises. Interview conducted with Resident #1 (R1) revealed there was an incident with Resident #2 (R2) where they were walking down the wrong hallway and R1 told them that it was not their room and R2 Unfounded proceeded to hit R1, causing R1 to fall to the ground. Per a record review of Unusual Incident/Injury report submitted to the department revealed that on 04/15/25 there was an incident involving R1 and R2 being involved in an incident where R1 was sent out due to a lump on the back of their head, and law enforcement being contacted. In addition regarding R2 due to their increased agitation, R2 followed up with their Primary Care Physician and the facility implemented and alert charting. Based on interviews and record review the allegation of staff did not prevent an unknown individual access to the facility resulting in a resident being physically attacked while in care is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted and a copy of this report, 9099C, LIC811-Confidential names list was reviewed and provided to Lavina Dubose, Memory Care.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 18-AS-20250416103400

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to conduct a Case Management visit regarding an incident that took place on September 28, 2024. LPA spoke with Lorena Oropeza, interim executive director, and obtained pertinent documentation. LPA inspected the interior and exterior areas of the home. There were no health and safety concern at the time of inspection. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report were provided to Lorena Oropeza.the state’s words, verbatim · CDSS document, Jan 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ferrer Sabarias conducted a required annual visit. LPA was greeted and was granted entry and met with Business Office Manager Shelby Walker, who was informed of the purpose of the visit. The facility is comprised of (2) one story buildings with (28) resident rooms and (16) bathrooms, outdoor space and common areas. The facility does not have a pool or fire arms. The facility is designated as a residential care facility for the elderly for elderly ages 60 years and above. The facility is approved for delayed egress. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations in the facility. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The dangerous items were observed to be locked and inaccessible to clients. LPA observed the operating facility signaling system. LPA observed activity areas for residents to engage in. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication were secured in a medication room. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. A planned fire drill was conducted during the time of the visit. LPA observed the smoke detectors and fire alarms were functional during the time of the visit. LPA observed all facility exits were clear from obstructions. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Business Office Manager Shelby Walker.the state’s words, verbatim · CDSS document, Jan 17, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to amend a complaint report. The LPA met with Interim-Executive Director, Lorena Oropeza, and informed her of the purpose for the visit.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Facility retaining residents who need a higher level of care.

Licensing Program Analysts (LPAs), Stephanie Martinez and Ferrer Sabarias, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPAs met with Administrator, Shannon Moore Wilkerson, and informed her of the purpose of the visit. A report was received by the Department alleging the licensee admits residents into the facility who have a mental disorder requiring a higher level of care than can be met by the facility. The investigation included staff interviews, review of records and collection of relevant documentation. An interview with a witness revealed there are at least two residents in care who do have a mental disorder requiring a higher level of care. LPA Martinez reviewed the medical assessments (Physicians Report for Residential Care Facility for The Elderly) for both residents identified, Resident One (R1) and Resident Two (R2). Neither report noted either R1 or R2 were diagnosed with a mental disorder as alleged by the witness. Interviews were conducted with the offices of the medical providers for both residents. A representative for R1's Physician reported that R1 is diagnosed with a mental disorder, despite the signed physician's report not identifying the specific condition. The Physician for R2 reported they were unaware of any mental health condition the resident was alleged to have had. Therefore, due to conflicting information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with the Administrator and a copy was provided. Unsubstantiated THIS PAGE WAS INTENTIONALLY LEFT BLANK.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 18-AS-20240131082100

Allegation investigated: Unqualified staff giving residents injections

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Shannon Wilkerson, Administrator, and informed her of the purpose for the visit. A report was received alleging residents in care are receiving injections from unqualified staff. According to Administrator Wilkerson, there has only been two residents in care, in the last four (4) months, who have required injections. She reported it is only the staff who have a LVN (Licensed Vocational Nurse) license, or herself, who will administer injections to residents in care. Staff interviews and records refuted the Administrator’s statement. Two out of four staff interviews revealed medication technicians, who are not considered appropriately skilled professionals, have been observed to administer injections to residents in care. In addition, Resident One's (R1's) and Resident Two's (R2's) Medication Administration Records, revealed Staff One (S1) and Staff Two (S2) administered injections to R1 in November and December 2023 and to R2 in January and February 2023. According to Administrator Wilkerson, she was present to provide Substantiated residents with their injections and could not initial the MAR due to the functions of the electronic MAR. No notes were found on the MAR to indicate the Administrator, rather than S1 or S2, had administered the injections. Therefore, based on interviews and records review, this allegation is deemed SUBSTANTIATED at this time. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted; this report was reviewed with Administrator Wilkerson and a copy was provided, along with LIC 811 and instructions on appeal rights.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 18-AS-20240131082100

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(b)(1) · Plan of correction due date: Feb 9, 2024

INJECTIONS: (b)...the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement was not met, as evidenced by: Based on interviews & records review, the Licensee didn't ensure staff who were appropriately skilled professionals administered injections to residents who required assistance. Staff interviews & MARs revealed staff who are not appro. skilled professionals were administering injections.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Administrator Wilkerson stated a physical copy of the Medication Administration Record (MAR) will be utilized when she or another individual is administering injections.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Executive Director, Shannon Moore, who was informed of the purpose of the visit. The facility is comprised of (2) one story buildings with (28) resident rooms and (14) bathrooms, outdoor space and common areas. The facility does not have a pool or fire arms. The facility is designated as a residential care facility for the elderly for elderly ages 60 years and above. The facility is approved for delayed egress. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations in the facility. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The dangerous items were observed to be locked and inaccessible to clients. LPA observed the operating facility signaling system. LPA observed activity areas for residents to engage in. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. Client files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication were secured in a medication room. LPA reviewed client medications and found all medication listed on MARS and all required labeling was found to be in place. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. A planned fire drill was conducted during the time of the visit. LPA observed the smoke detectors and fire alarms were functional during the time of the visit. LPA observed all facility exits were clear from obstructions. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Executive Director, Shannon Moore.the state’s words, verbatim · CDSS document, Jan 19, 2024

Allegation investigated: Inappropriate interactions between resident's in care.

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Administrator Shannon Moore informed them of the purpose of this visit. During this investigation LPA conducted interviews with staff and residents; obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined. Allegation #1 – Inappropriate actions between residents in care. The allegation stated that Resident One (#R1) was involved in a physical altercation with Resident Two (#R2). Allegedly, R1 threw a punch, and struck R2. When R1 punched R2, R2 bit R1 on the hand, causing a minor breakage of the skin. Staff interview revealed that both Unsubstantiated R1, and R2 were transported to the hospital for evaluation for minor medical care, and both residents returned to the facility without further incident. Through record review, LPA discovered that R1 has aggressive behaviors documented in their Physician’s Report, and R1’s care plan noted that R1 needs supervision for a multitude of reasons, including aggression. Staff schedule revealed that staff were present in the facility providing supervision to residents. Interviews with staff confirmed that staff were in the area, and further revealed that they responded quickly to the outburst of behaviors between the residents; thus, this allegation was Unsubstantiated. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of this report was reviewed with and provided to Administrator Shannon Moore.the state’s words, verbatim · CDSS document, Jan 3, 2024 · control 18-AS-20211213172614