Divine Mercy Guest Home II

Type of visit: Case Management - Other

On 4/1//23 at 1:55 p.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility as an announced visit to collect original report and provide amended report. LPA was greeted by Administrator Ulysis Baal, explained the reason for the visit, and allowed entry into the facility. LPA explained the original report needs to be collected. Original report was previously emailed due to LPA having printer issues. LPA informed Administrator the email sent on 2/6/23 containing the original report is no longer valid. Amended report was provided today 4/11/2023. Exit interview conducted and LIC809 & amended report provided.the state’s words, verbatim · CDSS document, Apr 11, 2023

Allegation investigated: Facility not providing proper medical care for residents

Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to investigate a complaint. LPA explained the reason for the visit and requested staff contacted Administrator. LPA was met by caregiver S1 who greeted and allowed entry into the facility. Caregiver S2 contact Administrated (AD) and completed tour with LPA. AD arrived later. S2 stated there are currently 5 residents at the facility. LPA observed all residents in their rooms. One room was shared by 2 males residents, another room is waiting for the arrival of a new resident, another room had one resident asleep, and the last room was shared by two female residents. LPA requested a copy of personnel roster and resident roster with emergency contact information. 1. The Department investigated the allegation: Facility not providing proper medical care for residents. Multiple residents were interviewed. None of the residents who were interviewed voiced concerns regarding medical needs were not being met. See LIC9099C for the continuation of this report. Unsubstantiated Based on interviews conducted and record reviews, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore the allegation is unsubstantiated. Verification of doctor's appointment was provided for resident R1. No citation was issued for the allegation. An exit interview was conducted, and a copy of this report was left with AD Susan Baal, whose signature on this form confirm receipt of these documents. Due to printer issues LPA emailed LIC9099.the state’s words, verbatim · CDSS document, Feb 3, 2023 · control 24-AS-20230125091224

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced for case management. LPA explained the reason for the visit and requested staff contact AD. LPA was met by caregiver S1 who greeted and allowed entry into the facility. Caregiver S2 contact Administrated (AD) and completed tour with LPA. AD arrived later. S2 stated there are currently 5 residents at the facility. LPA observed all residents in their rooms. One room was shared by 2 males residents, another room is waiting for the arrival of a new resident, another room had one resident asleep, and the last room was shared by two female residents. During the tour of the facility LPA observed the cabinet under the sink had a broken lock. Cabinet contained cleaning supplies/chemicals. LPA explained chemicals must remain locked at all times and this is a deficiency. LPA also observed scissor on the counter top and knives left unlocked. LPA did observe caregivers preparing lunch and reminded caregivers to keep all sharps locked and inaccessible to residents. Due to the circumstance no discrepancies were found for the sharps. An exit interview was conducted, and a copy of this report, LIC809D, and appeal rights were left with AD Susan Baal, whose signature on this form confirm receipt of these documents. Due to LPA having issues with the printer LIC809, LIC809D, and appeal rights sent by email.the state’s words, verbatim · CDSS document, Feb 3, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Feb 4, 2023

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed cleaning supplies/chemicals under the sick with a broken lock. and accessible to residents. LPA observed knives and others sharps as not locked and accessible to residents.the state’s words, verbatim · CDSS document, Feb 3, 2023

Plan of correction: Chemicals will be removed from under the sink and placed somewhere locked and inaccessible to residents. POC completed today.

Type of visit: Required - 1 Year

On 8/22/22 at 8:50 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensees Susan Baal and Ulysis Baal arrived a short time later. LPA toured inside and outside of the facility. No obstructions observed and pool gate in backyard was observed locked and inaccessible. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Beds in the shared bedrooms were observed to be at least 6 feet apart. LPA checked residents’ locked medications and observed a 30-day supply. Food supply was checked. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Facility staff observed to be wearing facial coverings. Resident’s files have updated emergency contact information. Administrator certification is current. The following deficiencies were observed: 1. S1 was working in the facility and was not associated to the facility. S1 had worked two days in the facility. 2. LPA found that the cabinet door, where centrally stored medication is kept, was unlocked and accessible. Deficiencies are being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A civil penalty is being assessed in the amount of $100 per day, for a total of $200. See LIC421BG for more details. An exit interview was conducted. A copy of this report and appeal rights were discussed and left with Licensee Susan Baal, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 22, 2022

Type of visit: Case Management - Incident

On 7/14/22 at 8:40 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - incident inspection. No residents reside at the facility. LPA called Licensee (LIC) Susan Baal and explained reason for inspection. LIC arrived a short time later and granted entry. LPA conducted initial inspection on 5/17/22 and was returning to discuss the incident that occurred on 2/3/22. After interviews conducted and records review, LPA determined facility did not violate any CCR Title 22 regulations. No deficiencies cited during this inspection. Exit interview conducted. A copy of this report was given to Licensee Susan Baal, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Jul 14, 2022

Type of visit: Case Management - Other

On 5/17/22 at 12:30 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other inspection. R1 now resides at Divine Mercy Guest Home IV #157206697. LPA conducted inspection and interview at Divine Mercy Guest Home IV. On 2/4/22, CCL received an incident report concerning R1. LPA conducted interview and reviewed records. Due to time constraints, LPA will return to continue the case management inspection. Exit interview conducted. A copy of this report was provided to Licensee Susan Baal, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, May 17, 2022

Allegation investigated: Illegal Eviction.

On 1/31/22 at 12:55 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an initial 10-day complaint inspection. LPA explained reason for inspection and was granted entry. Licensee (LIC) Susan Baal and Licensee Ulysis Baal arrived a short time later. LPA conducted interviews and reviewed records. Based on interviews and records reviewed, LPA found that LIC did not issue proper eviction notice to R1. R1 was admitted to the hospital and upon hospital discharge, LIC admitted to refusing R1's return to the facility because R1 was positive for COVID-19 and did not want to infect the other residents. Facility submitted an approved mitigation plan LIC808 to CCL on 2/25/21. Therefore, the above allegation is substantiated. A deficiency is being cited based on LPA observation, interviews conducted, and records review in accordance with the California Code of Regulations, Title 22, see LIC9909D. ***Continue on LIC9099C.*** Substantiated ***Continued from LIC9099.*** An exit interview was conducted. Due to COVID-19 precautionary precautions, this report and appeal rights will be emailed to the email on record with "Read receipt" to confirm receipt of this report. LPA verified with LIC that the email on record is current.the state’s words, verbatim · CDSS document, Jan 31, 2022 · control 24-AS-20220131091233

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Feb 7, 2022

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by: LPA found that LIC did not issue proper eviction notice to R1. R1 was admitted to the hospital and upon hospital discharge, LIC admitted to refusing R1's return to the facility because R1 was positive for COVID-19 and did not want to infect the other residents. Facility submitted an approved mitigation plan to CCL on 2/25/21. This poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2022

Plan of correction: Licensee will submit proof of in-service training of mitigation plan LIC808 review for both Licensees to CCL by POC due date.

Type of visit: Required - 1 Year

On 08/09/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct an Annual Inspection - Infection Control. LPA contacted Administrator via telephone, introduced self, and stated the purpose of the visit. Administrator, Susan Baal arrived a short time later. The facility has one central entry and exit point. LPA observed visitor log-in/screening upon entry to the facility. LPA conducted a facility tour with the Administrator. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Beds in the shared bedrooms were observed to be at least 6 feet apart. LPAs checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility has a central supply of PPE that is provided to the facility. PPE supplies is checked daily. Staff records were reviewed for good health and infection control training. Facility staff observed to be wearing facial coverings. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Administrator certification is current. No deficiencies were observed. Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be provided via email and an electronic read receipt confirms receiving this document. Report was signed.the state’s words, verbatim · CDSS document, Aug 9, 2021