Drake House

Type of visit: Case Management - Incident

On 9/5/2023, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a case management inspection. LPA met with Administrator Julie Huynh and announced the purpose of the visit. This visit was conducted in order to follow up on an incident which occurred on 8/22/2023 and was reported to CCLD on 8/23/2023. During the visit, LPA interviewed Administrator and obtained records. On 8/22/2023, a facility resident, Resident 1(R1), was admitted to Community Hospital of the Monterey Peninsula. R1 was discharged back to the facility on 8/28/2023 and returned to the facility with a diagnosis of pneumonia. No deficiencies were cited during the inspection. A copy of the report was provided and exit interview conducted with the administrator.the state’s words, verbatim · CDSS document, Sep 5, 2023

Allegation investigated: Staff yelled at resident Staff did not administer resident's medications as prescribed

On 8/2/2023, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct an initial 10-day complaint inspection. LPA met with Administrator Julie Huynh and announced the purpose of the inspection. LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. During the course of the investigation, the department conducted inspections, conducted interviews, and reviewed records. Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 2, 2023 · control 24-AS-20230727135912

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 6/29/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced at the facility to conduct a Required Annual Inspection. LPA met with Administrator Julie Huynh. LPA toured the facility inside and outside. Pathways and doors were clear and free from obstruction. Smoke-detectors and carbon-monoxide detectors were present and operational, and the facility has a sprinkler system. LPA observed sufficient amount of perishable and non-perishable foodstuffs. Common areas were clean, adequately furnished, and adequately lit. Resident bedrooms were clean and had required minimum furnishings. Resident bathrooms were clean, odor free, and water temperature was within required temperature range. Sharp items and detergents were secured in a locked cabinets. Medications are stored in a locked medication room, and medications appeared to be properly administered. The outdoor area was clean and free from hazards. LPA reviewed facility plan of operations and emergency disaster plan: last fire drill was conducted 5/24/2023. LPA reviewed a sample of staff and resident files. All staff files contained records of required training. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan, and a copy of current Administrator’s Certificate to update the facility file. No deficiencies were cited during the inspection, exit interview conducted with Administrator, a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 29, 2023

Allegation investigated: Facility staff mismanaged resident's medications.

This is an amended version of original report created on 12/07/22 due to the error, it is recorded as confidencial report instead of public report. On 12/7/22 Licensing Program Analyst (LPA) V Gorban conducted an unannounced complaint inspection at 1000 hours. LPA met with Administrator Julie Huynh. The purpose of this visit is to deliver the finding of the investigation completed by the Department. During the investigation, LPA completed interviews, requested documentation and reviewed facility files. Resident (R1) had prescription medications in R1’s belongings and R1 ingested them as hospital lvisit report stated R1 polypharmacy. According to Administrator, R1’s medications are to be centrally stored and managed by designated facility staff as medications are to be strong narcotics: Ativan and Seroquel. Substantiated Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED at this time. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on LIC 9099-D. Failure to correct the deficiency may result in civil penalties. An exit interview was conducted, and a copy of this report dated 12/7/2022 along with Appeal Rights (LIC 9058) was provided to Administrator Julie Huynh whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Dec 7, 2022 · control 24-AS-20221025133053

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Dec 7, 2022

87465(h)(2) Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This reqirement was not met as evidenced by LPA. Based on interviews and records review, facility staff failed to secure and centraly store strong medications prescribed to resident which posses immediate health and safety risc to the resident.the state’s words, verbatim · CDSS document, Dec 7, 2022

Plan of correction: Per Administrator, facility will implement staf training and proceedure to safety search: medicatations, contraband, anything that needs to be stored and locked, of residentds upon coming back from outings. Training will be documented and copy reporte to department by 1/05/2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit regarding a self reported medication error that was received in Fresno Regional Office (RO) on 11/23/22. LPA met with Jenny Lambarte, Residential Services Manager during today's visit. Per report received in Fresno RO on 11/22/22, R1 received the incorrect dosage of medication. R1's physician orders were changed on 11/18/22, R1’s current medication dosage was increased. Facility received new medication delivery on 11/21/22 however failed to discontinue R1’s old prescription resulting in R1 receiving both dosages. R1’s physician was contacted and no additional medical treatment required. R1's conservator also notified by e-mail. LPA informed that staff will receive mandatory medication training on 11/30/22. LPA received copies of Physician report, physician orders, MARS, and e-mail to responsible party, Deficiency cited on the attached 809D Exit interview conducted. Appeal rights given.the state’s words, verbatim · CDSS document, Nov 29, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 30, 2022

Incidental Medical and Dental Care: (2) Once ordered by the physician the medication is given according to the physician's directions. **This was not met as evidenced by, on 11/23/22 facility self reported to Fresno RO medication error for R1 which occurred on 11/22/22.the state’s words, verbatim · CDSS document, Nov 29, 2022

Plan of correction: Facility will conduct Medication Training for Med Techs on 11/30/22. POC, sign in sheets and agenda will be submitted to Fresno RO office no later than POC due date.

Type of visit: Case Management - Other

On 11/29/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit to inspect construction of additional shower stall on 2nd floor of building. LPA conducted facility tour with Jenny Lambarte, Residential Services Manager. LPA observed facility now has 1 shower and 1 tub in the first floor shower room, and 4 shower stalls on the 2nd floor shower room, LPA received final copy of City of Monterey Permit paperwork during visit. No deficiencies cited during Case Management visit. Exit interview conducted and a copy of report provided for facility records.the state’s words, verbatim · CDSS document, Nov 29, 2022

Type of visit: Case Management - Incident

On 9/26/22, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management to follow up on in incident reported which occurred on and another reported to Department on 6/15/22 involving R2. LPA reviewed and obtained copies of R1’s Needs and Appraisal, physician report, training records, and vehicle records during case management visit. No deficiencies cited.the state’s words, verbatim · CDSS document, Sep 26, 2022

Type of visit: Required - 1 Year

On 9/26/22, Licensing Program Analysts (LPA) M. Medina unannounced Annual Required Infection Control Inspection. LPA observed a central entry point with a supply of hand sanitizer located upon entry. A sign in policy that includes documented routine symptom screening for visitors is currently being implemented to follow current visitation guidelines. LPA introduced self and stated purpose of visit , LPA met with Julie Huynh, Administrator Certificate #6036684740, expires 6/14/23. Facility toured with Jim Fletcher, Housekeeping/Maintenance Supervisor. Most bedrooms are double occupancy, with a minimum of 6-feet between beds. All resident bedrooms observed to have pull cords, when tested LPA observed staff response time to be under 2 minutes. Residents present during today's inspection observed to be sitting in dining/activity areas watching a televised music performance and others resting in their bedroom. Kitchen toured, LPA observed facility to have a 2-day of perishable and a 7-day supply of non-perishable food available. Medications are locked and secured in medication room, residents observed to have a 30-day supply of medication available. PPE is locked and secured and available if necessary. Facility is equipped with a pull station and sprinkler alarm system. Carbon Monoxide detectors observed to be operational during today's inspection. Fire extinguishers present with a service date of 03/08/22. LPA received copies of Administrator Certificate, CPR/First Aid Card, and LIC 610 Emergency Disaster Plan during inspection. No deficiencies observed. Exit interview conducted. Report signed on site and a copy provided to Administrator for facility records.the state’s words, verbatim · CDSS document, Sep 26, 2022

Type of visit: Office

An informal meeting was conducted by teleconference today to follow up on discussion to renovate an existing bathroom on the second floor to include an additional shower room to facility. The following were in attendance: Melinda Hoffmann, Licensing Program Manager Melinda Medina, Licensing Program Analyst (LPA) Amy McCabe, President JP Butler, Vice President Julie Huynh, Administrator During teleconference, facility agreed to submit a letter to Department with projected construction start and completion dates. Facility will remain at current capacity of 50 to remain in compliance. Once construction is completed and paperwork submitted to Department, facility may increase capacity to 55. Facility to contact LPA if any further questions. A copy of this report was emailed to Administrator for signature.the state’s words, verbatim · CDSS document, Apr 27, 2022

Type of visit: Office

An informal meeting was conducted by teleconference today to discuss capacity; specifically related to shower/tub requirements, and the following were in attendance. Melinda Hoffmann, Licensing Program Analyst (LPA) JP Bulter, Vice President Julie Huynh, Administrator Emilio Rubalcava, Program Director During a visit at the facility on 3/19,2022 , LPA Medina discovered that facility is licensed for a capacity of 55 residents and they have (5) showers/tubs. Title 22 regulations require that there be at least one tub or shower for each ten (10) persons. In order to correct this oversight, it was agreed that facility will submit a change of capacity to include the following forms and a $25 fee: LIC 200, LIC 500, LIC 610E, LIC 999, LIC 9054. If there are any changes to the above plan, the details will be memorialized in a subsequent report. A copy of this report was emailed to Administrator for signature.the state’s words, verbatim · CDSS document, Apr 6, 2022

Type of visit: Case Management - Other

On 3/19/22, Licensing Program Analysts (LPA) M. Medina and L. Salazar arrived at the facility to conduct a complaint visit and observed the following during facility tour: Facility has one operating shower for current census of 50 residents. Per staff conducting facility tour, showers on second floor are currently under repair. The above deficiencies are being cited on the attached 809D. An exit interview was conducted with Julie Huynh , signed on site and a copy of this report, Proof of Correction (LIC 9098) and Appeal rights will be provided via e-mail.the state’s words, verbatim · CDSS document, Mar 19, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(b)(2) · Plan of correction due date: Mar 31, 2022

PERSONAL ACCOMMODATIONS AND SERVICES: (b)Toilets and bathrooms shall be conveniently located. The licensed capacity shall be established based on Section 87158, Capacity, and the following: (2) At least one bathtub or shower for each ten (10) persons, which includes residents, family and live-in personnel.the state’s words, verbatim · CDSS document, Mar 19, 2022

Plan of correction: Facility restroom is being renovated and project is expected to be completed by Friday 3/25/22. Administrator to submit POC to Fresno CCL office by due date

Allegation investigated: Staff mismanaged resident’s medication Staff spoke inappropriately to resident

Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Jenny Lombarte Assistant Administrator. The Department received notice of the above complaint allegations on 9/16/2020. On 9/25/2020 Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit to open the 10 Day Complaint investigation. On 6/24/2021 conducted an on site complaint visit. LPA reviewed facility records, resident records to include physician's reports, appraisal needs and services plans, progress notes, and medication administration records. Between 9/25/2020 and 10/21/2021 4 staff and 12 residents were interviewed. 4 of 4 staff stated that there no mismanagement of R1's medications. Page 1 of 2 Unfounded 11 of 12 residents stated that they have not had any issues with their medication administration nor are they aware of any other resident having issues with medication administration. 1 of 12 residents R1 was unable to provide details of any incident of medication mismanagement. 4 of 4 staff stated that they did not speak inappropriately to residents and were unaware of any staff speaking inappropriately to residents. 11 of 12 residents are unaware of any situation in which staff spoke inappropriately to them or any other resident. 1 of 12 residents, R1 was unable to provide details of an incident in which staff spoke inappropriately to resident. Records reviewed included residents physician’s report, progress notes, appraisal needs and services plan and medication administration records to include PRN medication records. The PRN medication records did not record any errors or issues with the administration of PRN medications. This Department has investigated the complaint allegation listed. Based on interviews, review of records, the The Department has found that the complaint allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted with Jenny Lombarte Assistant Administrator and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 21, 2021 · control 26-AS-20200916101458

Allegation investigated: Facility is unsanitary.

Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint finding for the above allegation. LPA met with Jenny Lombarte Assistant Adminsitrator. The Department received notice of the above complaint allegations on 12/17/2020. On 12/24/2020 Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit via FaceTme to open the 10 Day Complaint investigation. LPA toured the facility. On 6/24/2021 LPA conducted an on site complaint visit and toured the facility. LPA interviewed 2 staff and 10 residents. LPA reviewed facility records to include Cleaning Schedulse and COVID Mitigation Prevention Plan. Page 1 of 2 Unfounded Between 12/24/22020 and 6/24/2021 4 staff (S1-S4) and 10 residents (R1-R10) were interviewed. 4 of 4 staff interviewed stated that residents’ rooms are cleaned and disinfected daily to include changing linens and rooms are deep cleaned once a week and as needed. S2 stated that common areas are cleaned and disinfected every shift and as needed. Soiled furniture that is not cleanable is immediately removed and disposed of. 10 of 10 residents interviewed stated the facility is clean and sanitary. Cleaning scheduled records confirmed completion of weekly deep cleaning of residents’ rooms for the periods of 11/30/2020 through 1/1/2021. During facility tours on 12/24/2020, 3/4/2021, 6/24/2021 and 10/21/2021, LPA observed the facility to be clean and sanitary. LPA did not observe any soiled furniture nor did LPA observe any towels or magazines on furniture to cover stains or dampness of furniture. The Department has investigated the complaint allegation listed. Based on interviews, observations and review of records, the Department has found that the complaint allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted with Jenny Lombarte Assistant Administrator and a copy of this report provided. Page 2 of 2the state’s words, verbatim · CDSS document, Oct 21, 2021 · control 26-AS-20201217160944

Allegation investigated: Resident's room has an odor Staff did not treat resident appropriately

Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Jenny Lombarte Assistant Administrator. The Department received notice of the above complaint allegations on 12/29/2020. On 1/8/2021 Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit to open the 10 Day Complaint investigation. On 6/24/2021 LPA conducted an on site complaint visit and toured the facility. Between 1/8/2021 and 10/21/2021 5 staff and 11 residents were interviewed. Records reviewed included residents’ records, Admission Agreement, Progress Notes and Privacy Polices. Page 1 of 2 Unsubstantiated Also, LPA reviewed Deep Cleaning Schedule for 12/30/2020 through 1/1/2021 and Laundry Schedules for 12/30/2020 through 1/30/2021. 4 of 4 staff (S1-S4) are unaware of any odor issues in R1’s room. 10 of 10 residents interviewed stated the facility is clean and sanitary. These residents were unaware of any odor issues in R1’s room. Deep Cleaning Scheduled notes R1’s room was deep cleaned on 12/14/2020. S4 Housekeeping staff stated that the residents’ rooms are cleaned daily and laundry service is done on a daily basis or as needed. 3 of 4 staff stated that they were unaware of anytime staff spoke to or treated a resident disrespectfully. 4 staff member does not get involved with direct care of residents. 10 of 10 residents did not see or hear staff treat a resident inappropriately. The Department has investigated the above complaint allegations. Based on information from interviews conducted , observations and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No Deficiencies cited under California Code of Regulations Title 22 Exit interview conducted with Jenny Lombarte Assistant Administrator and a copy of this report provided. Page 2 of 2 Records reviewed included residents’ records, Admission Agreement, Progress Notes, Theft Loss and Prevention Program and Privacy Polices. Also, LPA reviewed Laundry Schedules for 12/30/2020 through 1/30/2021. 4 of 4 staff were unaware of any lost or missing laundry. S2 stated that they ask residents to update their personal inventory list but sometimes residents do not. All clothing items are initialed by staff to identify the resident’s clothing to prevent items getting mixed up or lost. S1 stated that sometimes clothing items get mixed up during laundry service and staff will look for the items to return to the owner. Progress Notes dated 1/13/21 indicate that R1 reported to staff that 2 missing clothing items were found. R1 did not have these items initialed before giving them to housekeeping for washing. Theft and Loss Prevention Program states: "The facility shall not be liable for items , which have not been inventoried" 10 of 10 residents did not have any issues or concerns with laundry service or their personal property. 2 of 4 staff were unaware of any privacy issues and stated that office space is made available to residents for their use to speak privately with others. The other 2 Staff members do not provide direct care services. Admission Agreement States under Item 17. PRIVACY states “Sleeping and bathroom/bathing areas are private. Staff and residents must knock on closed bedroom or bathroom doors, wait a minute, call out before entering". 10 of 10 residents did not have any concerns or issues regarding privacy. Privacy is provided when requested. Page 2 of 3 On 6/24/2021 and 10/21/2021 during site tours, office space was observed for residents' use if requested. This Department has investigated the complaint allegations listed. Based on interviews, observations, review of records, the Department has found that the complaint allegations are UNFOUNDED, meaning that the allegations are false, could not have happened and/or is without a reasonable basis. Exit interview conducted with Jenny Lombarte Assistant Administrator and a copy of this report provided. Page 3 of 3the state’s words, verbatim · CDSS document, Oct 21, 2021 · control 26-AS-20201229134852

Allegation investigated: Facility not properly preparing food

Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Jenny Lombarte Assistant Administrator. The Department received notice of the above complaint allegations on 2/26/2021. On 3/4/2021 Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit via FaceTime to open the 10 Day Complaint investigation. LPA toured the facility. Between 3/4/2021 and 6/24/2021 4 staff and 11 residents were interviewed. Records reviewed included resident Menu for 1/31/2021 through 3/6/2021, Resident Diet Orders, Refrigeration Temperature Logs for 2/2021. Page 1 of 2 Unsubstantiated 4 of 4 staff stated that food was properly prepared and no undercooked food served to residents. S2 stated that the food temperature is checked upon completion of the cooking process and then placed in the oven to keep warm. Prior to serving the food temperature is checked again before service. All staff were unaware of any issues with food service. 10 of 11 residents stated that they did not have any issues with food service nor where they served undercooked food. 1 of 11 residents stated that a hamburger served was pink in the middle. R5 told staff and the cook corrected the concern. There were no further issues. R5 could not provide further details of this event. Temperature Logs were reviewed. Refrigerators and freezers temperatures were maintained within a Safe Temperature Zone. Refrigerators temperatures recorded at 40 degrees F or below and Freezers at 0 degrees F or below for the Month 2/2021. Based on information from interviews conducted and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted with Jenny Lombarte Assistant Administrator and a copy of this report provided. Page 2 of 2the state’s words, verbatim · CDSS document, Oct 21, 2021 · control 26-AS-20210226162619

Allegation investigated: Facility is not providing a comfortable outdoor space for residents.

Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint finding for the above allegation. LPA met with Jenny Lombarte Assistant Administrator. The Department received notice of the above complaint allegations on 5/5/2021. On 5/6/2021 Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit via FaceTime to open the 10 Day Complaint investigation. On 5/6/2021, 6/24/2021 and 10/21/2021 conducted tour of the facility inside and out. Between 5/6/2021 and 6/24/2021 LPA interviewed 4 staff and 10 residents. Page 1 of 2 Unsubstantiated 4 of 4 staff stated the facility provides comfortable outdoor space for residents. The back patio area is cleaned a minium of 2 times a day and as needed. 9 of 10 residents stated the staff clean the area regularly to keep it clean and comfortable. 1 of 10 , R9 does not like the smoke from the designated smoking area but would not use the area anyway. R5 stated that some residents do not discard their cigarette butts is the trash receptacle. Based on information from interviews conducted, observations and records reviewed, although the allegations listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted with Jenny Lombarte Assistant Administrator and a copy of this report provided. Page 2 of 2the state’s words, verbatim · CDSS document, Oct 21, 2021 · control 26-AS-20210505154404