El Rio Memory Care Community

Allegation investigated: Licensee is not addressing a scabies outbreak at the facility. Staff are not following reporting protocols as necessary. Facility does not have adequate supply of PPE for staff Staff do not ensure infection control guidelines are being followed

Unannounced complaint visit made out to this facility on 06/30/2026 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated representative, Reshmika Sharma, who was briefly interviewed at this time. Current census was 55 residents. The purpose of this visit was to deliver the findings to this facility, and its representative, in regards to the above allegations at this time. Based on a review of the forms and documents gathered during the course of this investigation, it was learned that Personal Protective Equipment (PPE) were purchased on a monthly basis since the discovery of residents with the rashes and possible scabies. A review of the invoices revealed that gowns, shampoos, and gloves, along with other disinfectants, were purchased from a third party vendor and delivered to this facility on a weekly basis. Based on a review of the forms and documents gathered during the course of this investigation, it was learned that notifications to the families and responsible parties of the residents in care went out on 05/19/2026. It was learned that this was sent out via email to all of the email addresses linked to the Unsubstantiated residents in care. Based on a review of the forms and documents gathered during the course of this investigation, it was learned that notification to the Department of Social Services, Community Care Licensing Division, was first received on 05/18/2026 by this LPA from the facility Resident Services Director Reshmika Sharma. Based on a review of the forms and documents gathered during the course of this investigation, it was learned that notification to the Stanislaus County Health Services Agency (SCHSA) was sent out on 05/15/2026. There were emails and communications held with this agency from this facility throughout the discovery of the rashes and possible scabies with facility residents up until the clearance of a negative result for the last resident for scabies through skin scrapings and biopsies that were performed during this time. It was learned that upon discovery of the rashes and possible scabies outbreak, facility care staff were instructed to adhere to the Infection Control plan and all affected residents were then isolated and monitored with treatment as prescribed by their attending licensed medical professionals. It was learned that affected residents were scheduled with their primary care providers (PCPs) for further treatment and scheduled additional tests as well. Based on interviews conducted during the course of this investigation, it was learned that this facility did act accordingly to it's policies and procedures set forth in it's Infection Control Plan and involved all necessary parties with notifications and continuous updates. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 30, 2026 · control 27-AS-20260518154050

Type of visit: Required - 1 Year

On 12/02/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by Staff Member (SM), Rita Southammavong and explained the purpose of the visit. LPA asked SM Southammavong to call the Facility Designated Administrator (FDA), Theresa Pettapiece that CCL was present. Shortly after, FDA Pettapiece arrived and met with LPA Pascua. Current census was 63. A brief interview with FDA Pettapiece was conducted. This facility is a full memory care facility licensed to hold and retain 72 non-ambulatory residents with a hospice waiver for 18. In addition, the facility has been approved for delay egress throughout the facility perimeter. LPA Pascua reviewed 5 resident files and 5 staff files. All files were complete and in compliance at this time. The FDA has a current and active administrator certificate #7025930740 and expires on 07/07/2027. There are currently 14 residents on hospice and 1 resident receiving home health services. A tour of the facility was conducted. This facility has a total of 60 bedrooms in which all are cleared for non-ambulatory residents. In addition, any bedroom can be used for a bedridden room. All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time. Office rooms and other areas intended for resident use were toured. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Knives were observed to be locked and made inaccessible to the residents at this time. It was observed in that the facility has cafe areas equipped with a microwave and addition refrigerator present to cool, heat, and warm up food of the residents if necessary. Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time. A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to sufficient and able to meet the needs of the residents at this time. A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Additional incontinent supplies were also identified. Medication room was reviewed. It was learned that narcotics and all other medications were housed in medication carts that were used to store and dispense medications to the residents at this time. This facility has an electronic Medication Administration Record system. A brief interview was conducted with facility staff responsible for handling, dispensing, and documentation of the medications at this time. First aid kit was observed to be present and contained all of the required components at this time. First aid kit was observed to be present and contained all of the required components at this time. A tour of the facility memory care unit was conducted. Exterior grounds of this facility was toured. Perimeter fence and gates were observed to be functional and in good repair at this time. Delayed egress and other safety measures were observed to be functional at this time. Fire extinguishers, located and placed throughout the facility, were observed to have been annually inspected on 09/03/2025 by the local fire extinguisher company noted as Silicon Valley Fire and in compliance at this time. All smoke and carbon monoxide detectors were present and working at this time. The following forms and documents were requested to be updated and submitted into CCL: -LIC 308 -LIC 400 -LIC 500 -LIC 610e As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to Facility Designated Administrator.the state’s words, verbatim · CDSS document, Dec 2, 2025

Type of visit: Case Management - Legal/Non-compliance

On 9/11/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) Lisa Rios arrived at the facility unannounced to conduct a visit to ensure compliance with Health and Safety Code (HSC) 1569.38 - Posting of licensing reports; disclosure to new residents. LPA Lindstrom and LPM Rios met with Administrator Theresa Pettapiece and explained the purpose of today's visit. The facility received the Accusation notifying that the department has commenced proceedings to suspend or revoke the license of the facility pursuant to Section HSC 1569.50, and is required to post this Accusation in a location easily viewable by residents and visitors. A written notice was handed to the Administrator of these accusations. The facility will comply with HSC 1569.38(a-h). The Administrator was asked to post the accusation in the lobby where it could easily be read and seen by current and new residents and families. LPA Lindstrom observed the letter sent to residents posted in the main lobby. The posting was displayed in a location easily viewable by residents and visitors. LPA Lindstrom interviewed the Administrator, who confirmed that a written notice dated August 19, 2025, was distributed to current residents within or on the tenth day after receiving the notification, as well as mailed by US Post to residents’ responsible parties. LPA Lindstrom was provided a copy of this notice by the Administrator during a site visit conducted on 8/21/2025. A licensee who fails to comply with the requirements of subdivision (b) or (c) of the HSC 1569.38 shall be liable for civil penalties in the amount of one hundred dollars ($100) for each day of the failure to provide notification as required in this section. The total civil penalty for each day shall not exceed one hundred dollars ($100) regardless of the number of notices that the licensee fails to send that day. The total civil penalty for a continuous violation of subdivision (b) or (c) shall not exceed five thousand dollars ($5,000). Based on LPA Lindstrom’s observation and interview, the facility is in compliance with HSC 1569.38. In addition, the Department will be contact the residents or responsible parties to verify that notice was received. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2025

Allegation investigated: Facility did not ensure that staff receive CPR/First Aid training

On 07/24/2025, LIcensing Program Analyst (LPA) Triel Ellen LIndstrom and Licensing Program Manager (LPM) Lisa Rios arrived unannounced to the facility to deliver complaint findings for the allegation that facility did not ensure that staff receive CPR/First Aid training. The LPA and LPM met with Reshmika Sharma, Director of Resident Services, explained the purpose of the visit, and conducted an interview. Allegation: Facility did not ensure that staff receive CPR/First Aid training On 4/28/2025, LPA Arielle Pascua visited the facility and requested an employee roster and a copy of all current staff’s CPR/First Aid training on file. LPA Lindstrom reviewed this proof of training. She determined that all Med Techs and Licensing Vocational Nurses have valid training, but that only five of twenty-four Resident Assistants have valid CPR/First Aid training. Substantiatedthe state’s words, verbatim · CDSS document, Aug 21, 2025 · control 27-AS-20250424151715

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Aug 25, 2025

Personnel Requirements: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training.. (1) Staff providing care shall receive appropriate training in first aid… This requirement is not met: Based on review of the facility policy, only one staff on premises is required to receive 1st aid training. This poses a potential risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: The facility will change their FIrst Aid policy to show that anyone providing assistance with activities of daily living will be required to be First Aid trained by a qualified professional. Within thirty days, staff will attend First Aid training and the Administrator will submit both a sign-in sheet from that training and a copy of First Aid certificates for all staff who assist residents with activities of daily living. These items shall be submitted to LPA Lindstrom at ellen.lindstrom@dss.gov.ca.

Allegation investigated: Staff restrained resident in care.

On 7/24/25 Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) Lisa Rios arrived unannounced at the facility to deliver the findings on a complaint submitted on 4/24/25. The LPA and LPM met with Reshmika Sharma and explained the purpose of the visit. The LPA had conducted inspections of the facility, interviews with residents and staff, and records review to investigate the two allegations. Allegation: Staff restrained resident in care. On 6/17/2025, LPA Lindstrom visited the facility and observed ten residents seated in rows in wheelchairs with a brake applied at a trivia group activity. She also observed at least half a dozen residents in wheelchairs without brakes on who were sitting elsewhere in the facility or propelling themselves forward through common areas with their feet. Unsubstantiated On 7/14/2025, LPA Lindstrom interviewed three Staff (S1, S2, and S3). S1 stated that wheelchair brakes were never applied for staff convenience, only for safety during meals, transfers, and group activities. S1 stated that staff were always present during these times to release the brakes when residents wanted to leave. S2 stated that staff applied wheelchair brakes at the dining room tables to prevent wandering and during group activities to keep residents in place. S3 stated that staff was not supposed to lock wheelchairs; staff let residents have free will. On 7/16/2025, LPA Lindstrom interviewed three Staff (S3, S4, and S5). S3 stated that staff locked one wheelchair brake during meals to reduce fall risks. S3 explained that one unlocked brake allowed residents to still self propel, which let staff know they wanted to leave. S4 stated that wheelchair brakes should be locked during resident transfers to and from wheelchairs. S5 stated that brakes were not to be used except for safety during meals, activities, and dangerous situations. On 7/16/2025, the LPA interviewed two Residents in wheelchairs (R1 and R2). R1 stated that he had gotten all the help he needed from staff with his wheelchair and that he had no complaints. R2 stated that he got the assistance he needed from staff with his wheelchair. On 07/16/2025, LPA Lindstrom observed four residents in wheelchairs watching a movie and eight residents in wheelchairs singing together in a group activity, all with no brakes applied. 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.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 27-AS-20250424151715

From the deficiency page

This 9099D was written in error.the state’s words, verbatim · CDSS document, Jul 24, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 06/17/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived for an unannounced case management site visit. The LPA met with Theresa Pettapiece, Designated Facility Administrator (DFA) Reshmika Sharma, Director of Resident Services (S1), and explained the purpose of the visit. The purpose of the visit was to check-in with facility administration about the Absence With Out Leave (AWOL) of a resident (R1) in their Memory Care unit, on 05/28/2025, which they self-reported by submission of a LIC624 Incident Report on 05/29/2025. The LPA conducted an interview with the DFA and S1 and requested records for review. S1 stated that R1's behavior was unusual the evening that she eloped from the facility, including both that she was awake at that hour and that she exited the door. Because of this unusual behavior, R1 received a medical evaluation after the incident to screen for underlying issues that included a urine analysis, which came back negative. The doctor adjusted R1's depression medication and she has since been calm and responds to redirection. After the incident, facility administration conducted a staff training on the "3 P's of Elopement Prevention," and provided the LPA with a Staff Service Plan (for R1) Review Acknowledgement signed by fourteen staff. During the training, management emphasized the importance of physically checking and laying eyes on the exit doors when a door alarm goes off, as well as not turning off alarms until staff has communicated with each other and this task has been done. The LPA requested a copy of the current and previous care plans and the LIC 602 for R1, which S1 provided. S1 stated that R1 is now classified as an elopement risk and that the new care plan included the instruction to check on her more frequently than the baseline hourly visual checks that staff performs. No deficiencies were cited during this site visit. An exit interview was conducted and a signed copy of this report was left with S1.the state’s words, verbatim · CDSS document, Jun 17, 2025

Type of visit: Case Management - Infectious Disease Outbreak

On 06/17/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived for an unannounced case management site visit. The LPA met with Reshmika Sharma, Director of Resident Services (S1), introduced herself, and explained the purpose of the visit. The purpose of the visit was to check-in with facility management about the recent COVID outbreak at the facility, which the facility had self-reported via email and submission of LIC 624 incident reports. The LPA conducted an interview of S1. Background Info: On 05/25/2025, S1 emailed the LPA to inform her that there was a COVID outbreak at the facility. S1 attached a COVID line list that listed six residents and 3 staff who had tested positive for COVID. S1 emailed an updated COVID line list on 06/06/2025 that listed a total of fifteen adults and nine staff (including those listed on the 05/25/2025 list) who had tested positive COVID. Interview: The LPA asked S1 to describe some of the infection control practices that the facility management implemented during this outbreak. S1 stated that the facility kept a close eye on residents and tested all residents who showed COVID-like symptoms, even those residents who just presented as more tired than usual. S1 stated that it isolated COVID-positive residents in their room to the extent possible, provided masks to residents and visitors, and tested other residents who had been in close contact with COVID-positive residents within seventy-two hours. Management also temporarily moved COVID-positive residents who lived in double-occupancy rooms into single-occupancy rooms to protect their roommates. S1 stated that isolation and temporary relocation helped stop the spread of the disease. The LPA asked S1 if management thought that the facility's infection control policy needed to be updated as a result of this outbreak. S1 stated that she did not think so and that their current policy provided adequate guidance. Management cross-reported new cases of COVID during this outbreak to public health, as well as alerted all employees and families of residents of the outbreak via an email newsletter. S1 stated that public health advised that isolation for COVID-positive residents could end when they were no longer symptomatic. S1 stated that there have been no further cases of COVID since 06/06/2025. No deficiencies were cited during this site visit. An exit interview was conducted and a signed copy of this report was provided to S1.the state’s words, verbatim · CDSS document, Jun 17, 2025

Type of visit: Case Management - Other

On 03/07/25, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct a Case Management visit. LPA Campbell met with Reshmika Sharma, Director of Resident Services (DRS) and explained the purpose of the visit. After requesting a roster of staff and hospice residents, LPA Campbell obtained the client Admission Agreements, admission orders from hospice, POA/resident hospice agreement the initial doctors referral for Hospice and conducted a tour of the facility and attempted to interview clients. The facility is licensed to service 72 clients, 15 hospice clients and is approved for delayed egress. Of the 15 hospice clients, LPA Campbell attempted to observe and interview 5 clients. Of those 5 clients, 4 of them (R1. R3, R4, R5) were either sleeping or declined to interact with LPA Campbell. LPA Campbell was able to speak to and observe R7 in their bed to confirm she was able to reposition herself in her bed and was thus not bedridden. R7 confirmed she was fine and that she liked living in the facility. R3 was also observed sitting up in a lounger watching a movie. LPA Campbell spoke with Reshmika Sharma, DRS regarding the facility. Hospice clients have case managers and nurses who visit them once a week. During the day, there is a nurse and Med Tech for the AM, PM and NOC shifts. Per DRS Sharma, there are 15 hospice clients in all currently. There are four third party hospice nurses assigned 2 to 3 clients each. There are also 2 to 3 third party shower aids that help clients with their bathing needs.. Facility staff also have 6 caregivers who assist 2 or 3 residents each along with 1 nurse and med tech every shift. Both hospice staff and facility staff (RA, nurses and Med Techs) work in tandem to service the clients regardless of if they are in hospice or not. DRS Sharma provided the requested documentation. Because the facility does not maintain the signed hospice agreements or doctors referrals on site, they instead had to request it from the different hospice companies they work with. DRS Sharma was able to obtain this documentation during the visit. However the facility does maintain the required admission documentation from the third part hospice service. When asked, DRS Sharma stated they had reviewed the hospice care waiver increase regulation and that they wanted to increase the number of hospice to 18 and would be willing to hire more staff. At LPA Campbell's request, DRS Sharma will send the signed hospice initiation forms for the selected hospice residents by end of day Monday. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. An exit interview was conducted with Rashmika Sharma, DRS and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 7, 2025

Allegation investigated: Resident sustained multiple falls in the facility resulting in multiple injuries Facility's neglect and lack of care failed resident resulting in resident being hospitalized due to severe dehydration Staff did not follow resident’s care plan.

On 12/19/2024 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to deliver findings for a complaint investigation related to the above listed allegations. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of today’s visit. During the course of this investigation the Department conducted interviews with current facility staff, former facility staff, hospice agency staff and facility residents. The Department also reviewed medical records, hospice agency record and facility records. Facility Records: Resident 1’s (R1) Facility Service Plan and Resident Assessment indicate R1 required full assistance in bathing, dressing, grooming, toileting, transferring/mobility, feeding and encouragement with hydration. Due to R1’s chronic illnesses and injuries, she required staff check on her every 30 minutes. Substantiated Facility Notes indicate R1 suffered unwitnessed falls in her bedroom on the following dates: -On 09/01/2024 at approximately 1958 hours, R1 was found on the floor lying on her right side on the fall mat. She complained of pain to her shoulder and right side of hip. No other injuries were visible. She was assisted to her bed and provided with pain medication. -On 06/03/2024 at approximately 2245 hours, R1’s bed motion sensor went off and R1 was found on the floor curled up on her left side. She had a large skin tear and complained of pain. R1 was transported to the hospital to be medically assessed. -On 05/10/2024 at approximately 2200 hours, R1 was found lying next to her bed. An assessment was completed, and no new injuries were located. R1 was assisted back to her bed. -On 05/04/2024 at approximately 0920 hours, R1’s bed motion sensor went off. Staff responded and found R1 on the floor. R1 stated she was trying to walk to the restroom and fell. She complained of pain to her back and left hip. R1 was transported to the hospital to get medically assessed. -On 05/03/2024 at approximately 1500 hours, R1’s bed motion sensor went off. Staff responded and found R1 sitting on her buttocks on the right side of her bed. R1 was assessed and no new visible injuries were noted. R1 did not complain of any pain. She was placed in her wheelchair and taken out into the hallway. -On 03/22/2024 at approximately 0115 hours, R1’s bed motion sensor went off. Staff responded and found R1 sitting on the floor next to her bed. She was assessed and her left wrist was swollen and discolored. R1’s left arm had some deformities. She could not remember how she fell. R1 was transported to the hospital to be medically assessed. -On 03/22/2024, at approximately 1530 hours, R1’s bed motion sensor went off. R1 was found sitting on the bathroom floor. No injuries were noted. R1 was assisted onto her wheelchair and brought to the main lobby. -On 02/26/2024 at approximately 1500 hours, R1’s bed motion sensor went off. Staff responded and found R1 sitting on her buttocks next to her bed. She was confused and disorientated. Staff attempted to place R1 back in her bed. However, R1 refused to. R1 attempted to stand up frequently despite the staff’s redirections. R1 was brought to the common areas for closer staff supervision. -On 11/13/2023 at approximately 2007 hours, R1 suffered an unwitnessed fall in the facility’s hallway. Staff observed her sitting on the floor beside her walker. R1 complained of minor pain in her buttocks. She was placed on her bed and provided with pain killers. -On 08/22/2023 at approximately 2207 hours, R1 suffered an unwitnessed fall in her room and was found sitting on the floor. R1 denied any pain. She was assisted to her bed and the bed motion sensor was reset. Hospice Agency Records: On 06/06/2024, R1 was admitted to hospice with a multitude of diagnoses. R1 was given a life expectancy of six months or less if the terminal illness ran its normal course. Per the most recent records, from 08/28/2024 to 09/06/2024, no respiratory distress was noted on R1, and her vitals were stable. Hospital Records: On 03/22/2024, R1 was admitted to an acute hospital regarding a fall she suffered at the El Rio facility. A medical assessment was completed, and R1 was found to have a fracture on her left wrist. On 05/04/2024, R1 was admitted to an acute hospital regarding a ground-level fall she suffered at the El Rio facility. She was found on the floor for an unknown period of time and her bed motion detector was off. A medical assessment was completed, and she was found to have a fracture of the thoracic vertebrae. R1’s blood pressure was low, and she was severely dehydrated with an acute kidney injury. R1 was confused, agitated, and aggressive towards medical staff. On 05/30/2024, R1 was admitted to an acute hospital regarding rectal bleeding. A colonoscopy was done which showed no bleeding on her ulcers. She was discharged on 06/03/2024 and returned to the El Rio facility. Later that day, at 2347 hours, R1 was re-admitted to the hospital regarding a recent unwitnessed fall she suffered at the El Rio facility. She complained of pain to her left arm. A medical assessment was completed, and no acute fractures were found. Due to her physical condition deteriorating, and her recent falls, R1’s daughter decided to release R1 back to the El Rio facility under hospice services. Interviews: During the course of a interview with a former staff member that is a Licensed Vocational Nurse (LVN), the LVN stated that the facility is understaffed and the staff are overworked and if the facility had the proper staff to client ratio, some of these incidents could have been prevented if staff had the time to conduct appropriate checks on the residents. The LVN said even though staff checked the staff log indicating they had checked on a resident, such as R1, the interviewee believed some staff did not conduct their hourly checks on time based on the amount of work and responsibilities they had. The LVN also said she believed R1 was dehydrated because staff did not have time throughout the day to encourage R1 to drink her liquids. The LVN said the reason she stopped working at the El Rio facility was due to the facility being poorly managed, understaffed, the staff being overworked and unable to provide the proper care and supervision for the residents. During the course of an interview with a current Resident Assistant (RA) the RA stated there were a few months when the facility was short staffed and unable to complete all the required tasks; including provide the appropriate care and supervision to all the residents. During that period, staff did not have the time to encourage residents to drink their water throughout the day. Allegation 1: Resident sustained multiple falls in the facility resulting in multiple injuries Resident 1 (R1) suffered approximately 9 unwitnessed falls while in care at the El Rio Memory Care facility, some resulting in fractures. Facility staff reported R1 was prone to falling due to R1’s mental and physical condition. To prevent or diminish the number of falls, facility staff indicated they provided R1 with a half-rail bed, a motion-sensor bed adjusted to higher sensitivity, a “fall mat” and constant staff supervision. Most of the staff reported R1 was to be checked every hour. The staff Hourly Check log indicates these checks were conducted every hour or longer. However, R1’s Facility Service Plan and Resident Assessment indicate R1 required staff checks every 30 minutes. Staff reported that for a few months, the facility was short-staffed and unable to complete all the tasks and provide proper resident care and supervision, including 30-minute checks. The allegation is SUBSTANTIATED based on the above. A finding of substantiated means the preponderance of evidence standard has been met. Allegation 2: Facility's neglect and lack of care failed resident resulting in resident being hospitalized due to severe dehydration On 05/04/2024, R1 suffered an unwitnessed fall for which required hospitalization. A medical assessment was completed, and R1 was diagnosed with acute kidney injury due to severe dehydration. An ‘acute’ illness means the illness developed recently. Facility staff reported R1 ate most of the meals given but refused to drink all the water provided. Some staff said that throughout the day they provided residents with water and encouraged them to drink it. However, other staff reported that for a few months, the facility was short staffed, and they were unable to complete all the tasks and provide proper resident care and supervision. This included encouraging residents, such as R1, to drink their water throughout the day. The allegation is SUBSTANTIATED based on the above. A finding of substantiated means the preponderance of evidence standard has been met. Allegation 3: Staff did not follow resident’s care plan. Facility staff reported R1 was prone to falling due to R1’s mental and physical condition. Most of the staff reported R1 was to be checked every hour. The staff Hourly Check log indicates these checks were conducted every hour or longer. However, R1’s Facility Service Plan and Resident Assessment indicate R1 required staff checks every 30 minutes. Staff reported that for a few months, the facility was short staffed and unable to complete all the tasks and provide proper resident care and supervision, including 30- minute checks. The allegation is SUBSTANTIATED based on the above. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) and/or the Health and Safety Code. Civil penalties are also being assessed in the amount of $1500.00. At this time civil penalty assessments are under review and additional civil penalties may be assessed pursuant to Health and Safety Code 1569.49. An exit interview was conducted and a copy of this report was given to Executive Director Theresa Pettapiece. A registered nurse (RN) arrived to assess R1 and R1 denied having any pain. R1 was pleasant and could not recall the fall. Vitals were within normal range. No new bruising noted. The RN spoke with R1's daughter and hospice and provided an update at 23:58. Based on the Hospice agency’s own documentation the hospice agency was notified of the unwitnessed fall in a timely manner therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted and a copy of this report was given to Theresa Pettapiece. proper food service, staff cannot force a resident to eat. Based on LPA Jensen's observations and interviews conducted the allegation of "Staff did not ensure resident was provided proper food service" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence doesn't prove it. Allegation 2: Staff did not meet resident’s toileting needs in a timely manner. Hospice records for Resident 1 (R1) note that R1 was observed to be clean and dressed. The medical records for R1 do not show any skin breakdown where a brief would be worn. There were no medical records reviewed diagnosing urinary tract infection. The facility has an incontinence plan that is in compliance with regulatory requirements. No residents interviewed complained that their toileting needs are not being met. Based on the above listed factors the allegation of "Staff did not meet resident’s toileting needs in a timely manner" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence doesn't prove it. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 27-AS-20240903153605

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 20, 2024

Basic services shall at a minimum include: 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 facility staff reporting they were unable to provide proper care and supervision due to being understaffed resulting in multiple falls with injury to R1. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: LPA Jensen has confirmed with the Executive Director that at least 8 new staff members have been hired since this complaint was filed and a new training program "Humanitude" has been implemented. No further plan of correction required.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 20, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: Based on facility staff not recognizing R1’s severe dehydration resulting in kidney injury. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: LPA Jensen has confirmed with the Executive Director that at least 8 new staff members have been hired since this complaint was filed and a new training program "Humanitude" has been implemented. No further plan of correction required.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Jan 16, 2025

Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: There is an adequate number of direct care staff to support each resident’s ...health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by facility staff stating they were unable to complete all required tasks which included checking on R1 every 30 minutes due to being understaffed. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: The Licensee agrees to submit a plan that ensures needs and service plans are followed.

Type of visit: Required - 1 Year

On 12 5/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Executive Director (ED) Theresa Pettapiece and explained the purpose of today's visit. LPA Jensen toured the grounds and observed all paths to be free of obstruction. There are two enclosed areas with outdoor furniture and shaded areas for client enjoyment. The facility has raised garden beds that residents can maintain. A delayed egress system is in place. LPA Jensen toured the interior of the facility. The facility has a lobby seating area upon entry that is adjacent to a conference room used for family care conferences, training and other administrative needs. The resident rooms and common areas are configured in a number 8 formation to encourage residents to walk and easily find their way back to their rooms. The facility staffs with nurses, medication technicians, care providers and there is a wound specialist is available as well. There are currently 10 hospice residents and the facility has a hospice waiver for 15. The nurses station is centrally located with several arm chairs directly outside the station and this area has become a a popular gathering junction for residents. There are also multiple "club rooms" where residents can congregate and watch movies or do activities or meet with family. LPA Jensen inspected multiple occupied living units and found them to be sanitary and adequately furnished. LPA Jensen also inspected the staff room, management offices and laundry room. The laundry room is locked and inaccessible to residents in care. The facility has a machine that attaches labels to clothing and every piece of clothing, including socks are labeled with the resident's name and room number. Adequate linens were observed to allow for frequent bedding changes. The thermostat was set at 74 degrees for the comfort of the residents. LPA Jensen inspected the bathrooms. There are grab bars available. The bathroom water temperature in a common area was determined to be within the required range. Continued on LIC 809C... LPA Jensen inspected the kitchen and observed it to be sanitary. The refrigerator and freezer temperatures were within the required range. No expired food was observed. Food was labeled with dates. There was 2 days of perishable food and 7 days of non-perishable food available. A snack consisting of french toast and fruit was being served. An enchilada casserole and vegetables were served for lunch. Kitchen equipment that was not in use was covered with plastic. The Ansul system was last serviced in September of 2024 and is in compliance. Documents were posted in the kitchen displaying all residents with special diets, changes to diets and the corresponding resident photo. Numerous activities were on the schedule for this day including sing-a-long, musical balloon games, relaxation manicures, abstract art class, sunshine club and daily chronicles. Several big events are scheduled this month for the holiday including "Santa Paws" wherein therapy dogs visit residents. The smoke detectors and carbon monoxide detectors are hard wired and in working order. The facility maintains first aid kits that are complete. No toxins or medications were observed to be accessible to residents in care. The facility sketches were posted throughout with exit routes clearly marked and the facility sketch accurately reflects the layout of the facility. All garbage cans were observed to have tight fitting lids. The facility liability insurance is current and compliant. The fire extinguishers are in compliance. Monthly disaster drills are conducted and logged. LPA Jensen reviewed the marketing materials and no issues were observed. LPA Jensen reviewed 6 staff files and determined them to be complete and in compliance. LPA Jensen obtained a copy of the current LIC 500. LPA Jensen interviewed residents during the course of this inspection who all advised they are satisfied with the care they receive, the activities and the food service. LPA Jensen interviewed staff, all of whom were able to answer questions sufficiently. Technical assistance was provided in the areas of medication management for new admissions and maintaining an odor free facility. No deficiencies were observed. An exit interview was conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 5, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

LPA Jensen arrived at facility unannounced to conduct a case management in relation to multiple death reports received. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of today's visit. LPA Jensen received multiple death reports for residents on hospice between the period of 11/2/24 and 11/9/24. LPA Jensen reviewed the Certificate of Death with physician attestation for resident 1 (R1) and immediate cause of death is listed as senile degeneration of the brain. LPA Jensen reviewed the Certificate of Death with physician attestation for resident 2 (R2) and immediate cause of death is listed as senile degeneration of the brain. The incident report or LIC 624A for R2 was sent to the Department on 11/7/24 and lists the date of death as 10/2/24. The death certificate lists the date of death as 11/2/24. There appears to have been a misprint on the LIC 624A sent to the Department and the reporting was in fact done in a timely manner. LPA Jensen reviewed the Certificate of Death with physician attestation for resident 3 (R3) and immediate cause of death is listed as Alzheimer's disease. LPA Jensen reviewed the Hospice Death Report Summary for R4 which lists the hospice diagnosis as senile degeneration of the brain and lists physical findings as no pulse or respirations, skin pale and cool. No deficiencies were observed. The reporting appears to be compliant. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Staff did not ensure that resident had eaten breakfast in a timely manner Residents are being neglected Staff did not provide a comfortable environment for residents

On 11/21/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a compliant investigation in to the above listed allegations. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of today's visit. During the course of the investigation LPA Jensen inspected the facility on 3 separate occassions. LPA Jensen also interviewed 6 staff members, 4 residents and 1 family member of a resident. Allegation 1: Staff did not ensure that resident had eaten breakfast in a timely manner LPA Jensen spoke to residents, family, care staff, and kitchen staff. All parties interviewed denied having any issues with getting meals on time therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Contiued on LIC 9099C.... Unsubstantiated Allegation 2: Residents are being neglected LPA Jensen interviewed staff members, residents and a family member. All parties interviewed denied having any concerns regarding the care they are receiving. LPA Jensen also toured the facility on 3 separate occasions and did not observe any evidence of neglect. The facility appeared to be appropriately staffed on all 3 occasions. LPA Jensen did observe 1 resident that was in need of incontinence care on one occasion and 3 residents in need of incontinence care on another occasion but these observations do not appear to rise to the level of neglect therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Allegation 3: Staff did not provide a comfortable environment for residents LPA Jensen inspected the facility on 3 separate occasions and on all occasions a comfortable and sanitary environment was observed. LPA Jensen also interviewed 4 clients and a family member, none of whom had any negative comments about their environment therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Technical assistance was provided on managed incontinence. No deficiencies are being cited. An exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 27-AS-20240816145258

Allegation investigated: Facility did not assess residents prior to admission. Staff does not meet resident’s dietary needs.

On 11/21/24 LPA Jensen arrived at facility to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of today's visit. During the course of this investigation LPA Jensen interviewed 2 former staff members, 7 current staff members, a resident family member, and 2 current residents. LPA Jensen also reviewed resident records and facility policy records. Allegation 1: Facility did not assess residents prior to admission Facility staff, with the exception of management, consistently indicated that while residents were assessed prior to admission, the assessments were often incomplete therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. Continued on LIC 9099C... Unsubstantiated LPA Jensen provided technical assistance on the importance of providing a thorough and complete assesment prior to admission. The Executive Director informed LPA Jensen that new policies are being implemented effective 12/1/24 which include an admission checklist to assist in this process. LPA Jensen reviewed the policy which includes a procedure for ensuring all preadmission documentation is complete and in the resident's record. Allegation 2: Staff does not meet resident’s dietary needs. LPA Jensen conducted interviews with staff, residents and a family member. None of the parties interviewed stated that staff failed to meet resident dietary needs. Kitchen staff interviewed indicated that they would benefit from additional training regarding renal diets but there was no evidence that an inappropriate diet was served to a resident in care and as such the allegation is UNSUBSTANTIATED. Technical assistance was provided on the benefit of nutritional education specific to elderly care. The Executive Director confirmed that a Culinary Director has been hired and that a meal attendance tracking system is being implemented to provide another layer of monitoring. No deficiencies were cited. An exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 27-AS-20240814122522

Allegation investigated: Staff did not ensure resident was allowed to remain in dining hall Staff does not ensure residents are able to have private visits

On 10/1/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a compliant investigation in to the above listed allegations. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of today's visit. During the course of the investigation LPA Jensen conducted interviews, conducted site inspections and reviewed records. Allegation 1: Staff did not ensure resident was allowed to remain in dining hall It was alleged that there was an occassion wherein a visitor observed staff asking a resident to leave the dining hall before having an opportunity to finish their meal. All parties interviewed stated that residents are afforded the opportunity to finish their meals and in fact offered seconds. It was also learned that the facility has residents that need to be redirected after they finish eating so that staff has an chance to clean the dining hall. Unfounded Allegation 2: Staff do not ensure infection control guidelines are being followed It was alleged that resident 3 (R3) was observed in a common area after being diagnosed with a transmittable skin condition. LPA Jensen reviewed R3's records and determined that R3's skin condition was recognized and treated to the point of no longer needing isolation prior to being observed in the common area. LPA Jensen also reviewed infection control in-service training and verified the training to be up to date. The facility maintains an approved infection control plan. LPA Jensen interviewed 5 staff and all staff interviewed stated that the infection control plan is appropriately followed. Based on the records reviewed and interviews conducted the allegation of "Staff do not ensure infection control guidelines are being followed" is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened, the preponderance of evidence does not prove it . An exit interview was conducted and a copy of this report was provided. LPA Jensen observed 2 meal services during this investigation and did not observe anything that would be considered a violation of regulation. Based on LPA Jensen's observations and interviews conducted the allegation is UNFOUNDED. A finding of unfounded means the allegation is false, could not have happened, or is without a reasonable basis. Allegation 2: Staff does not ensure residents are able to have private visits The facility has a mix of residents with private rooms and shared rooms. The facility also has numerous gathering areas and a large outdoor courtyard. It was alleged that a family member came to visit resident 1 (R1) and was not afforded the opportunity to have a private visit. R1 has a private room. Based on R1 having a private room and the facility having multiple other areas for gathering the allegation is UNFOUNDED. A finding of unfounded means the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 27-AS-20240722140824

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 8, 2024

Managed Incontinence ...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry...This requirement was not met as evidenced by: Based on the Executive Director's confirmation that a resident (R2) was in the common area in soiled clothing. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2024

Plan of correction: The Licensee is currently working with R2's physician and a specialist to properly assess and treat conditions causing the aggressive behavior. A revised incontinence care plan was also nimplemented. No further plan of correction required.

Allegation investigated: Staff are not properly trained. Staff are not meeting resident's hygiene needs.

Licensing Program Analyst (LPA) Maja Jensen arrived on 9/19/24 for an unannounced visit to deliver findings for complaint investigation received on June 25, 2024. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of the visit. Allegation 1: Staff are not properly trained During the course of this investigation, LPA Jensen conducted an interview with a staff member responsible for providing care to residents. During the course of this interview, the staff member advised LPA Jensen that they are responsible for providing care for a resident with pressure injuries and received no specialized training from the facility or an external agency on how to provide care specific to this client and the restrcited health condition. The staff member also advised that they received no training from the facility or an external agency specific to the use a hoyer lift despite the fact that the facility is home to a resident that requires it's use. Based on the interview conducted the allegation of "Staff are not properly trained is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met Substantiated Allegation 2: Staff are not meeting resident's hygiene needs. On 8/19/24 Licensing Program Analyst (LPA) toured the facility and observed resident 1 (R1) with a brief that was falling out of her pant leg. R1 advised LPA Jensen that she need assistance using the restroom so LPA Jensen pulled the call signal cord. After several minutes no staff members came to assist and LPA Jensen escorted the resident to the restroom and provided stand by assistance. On this same day LPA Jensen observed 2 residents wearing shirts soiled with food, several residents with no shoes and 1 resident that was walking around barefoot. Based on LPA Jensen's observations while touring the facility the allegation of "Staff are not meeting resident's hygiene needs" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 27-AS-20240625164056

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87611(c) · Plan of correction due date: Sep 20, 2024

Prior to accepting or retaining a resident with an allowable health condition as specified in Section 87618...facility staff shall have knowledge and the ability to recognize and respond to problems...This requirement was not met as evidenced by: Based on LPA Jensen's interview, the staff member provided care for a resident with a wound and a resident with a hoyer lift but received no specialized training on the wound care or equipment use. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: The Licensee agrees to send an attestation that all staff providing care for residents will be trained on providing care specific to the residents individual health conditions.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464 · Plan of correction due date: Oct 10, 2024

Basic Services Basic services shall at a minimum include: ...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 LPA Jensen's observation multiple residents were observed to be in need of assistance with grooming. This poses a potential risk to the safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee agrees to conduct training on personal grooming and to implement measures to document and ensure assistance with grooming occurs.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Maja Jensen arrived on 9/19/24 for an unannounced visit to follow up on a complaint investigation received on November 22, 2022. LPA Jensen met with Executive Director Theresa Pettapiece and explained the purpose of the visit. On March 14, 2023, the Department concluded a complaint investigation which alleged that the facility did not reposition a resident (R1) which resulted in a pressure wound, facility failed to seek timely medical care for a pressure wound, and facility staff neglected a resident, resulting in an injury. Allegations that the facility did not reposition a resident, resulting in a pressure wound, and that the facility failed to seek timely medical care for a pressure wound were substantiated. The licensee was cited for California Code of Regulations (CCR) CCR Sections 87465(a)(1) and 87465(a)(2). At the time of the complaint visit on March 14, 2023, two immediate civil penalties of $500 totaling $1000 were issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility failing to observe R1’s change in condition and failing to seek medical treatment on or about November 13, 2022, to November 17, 2022, when R1 was hospitalized for a stage 4 pressure injury and a diagnosis of sepsis. At the time of a complaint investigation visit on March 14, 2023, two immediate civil penalties, each in the amount of $500, were assessed, and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code Section 1569.49. Today, 09/19/2024, the Department will be assessing a civil penalty per Health and Safety Code Section 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since immediate civil penalties totaling $1,000 were previously assessed on March 14, 2023, the amount of the civil penalty issued today will be $9,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Executive Director Theresa Pettapiece and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Case Management - Health Checks

On 5/20/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly health and safety check. LPA Jensen met with Executive Director Carlin Robertson and explained the purpose of today's visit. LPA Jensen toured the interior of the facility. It was observed to be sanitary and free of odor. The residents were participating in a sing along led by a professional vocalist in the activity room. LPA Jensen tested the delayed egress at 2 exit doors. The doors have a 15 second delay and after pushing down on the door for 15 seconds it opens automatically. They were determined to be fully operational. There is also signage posted at doors with a delayed egress advising of the 15 second delay. As an alternative, the delayed egress doors can be opened immediately with a code. LPA Jensen toured the grounds and observed an outdoor area secured by fence. The outdoor area fence has no delayed egress and opens with a code. The fire clearance allows for delayed egress of not more than 30 seconds and states that the facility meets all requirements and systems have been tested and accepted. On 4/13/24 the facility conducted an in-service training on elopement prevention and response as well dementia behaviors. LPA Jensen toured the kitchen and observed in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. The kitchen was observed to be sanitary and all staff were observed to be following safe food service principals. LPA Jensen toured the medication room. The facility has recently integrated the facilities systems with the pharmacy system through August Health which allows them more efficient access to all resident medication information and flags any possible duplicate orders or errors. The facility is converting to E-MAR effective 5/31/24. LPA Jensen discussed innovations in incontinence care products with Wellness Director and Executive Director. The facility was observed to be in substantial compliance. No deficiencies were cited during the course of this visit.the state’s words, verbatim · CDSS document, May 20, 2024

Type of visit: Case Management - Health Checks

On 3/20/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly health and safety check. LPA Jensen met Carlin Robertson and explained the purpose of today's visit. LPA Jensen confirmed with the Director of Resident Services that there has not been any infectious condition outbreaks. The facility has recently had a leadership change and Carlin Robertson has been appointed as the new Executive Director. LPA Jensen provided technical assistance related to change in Administrator. Documentation to initiate the Administrator change will be sent by 3/25/24. During the course of an interview, Executive Director Carlin confirmed she spends in excess of 40 hours per a week at the facility. LPA Jensen reviewed 3 staff files and determined that 3 of 3 staff members have a current first aid certification. LPA Jensen reviewed 3 resident files. LPA Jensen observed 3 of 3 resident files to have current Physician Reports and current Needs and Service Plans. LPA Jensen toured the facility and observed clients engaged in group activities. Freshly baked apple pie was being served for snack. LPA Jensen observed the food supply and determined there was in excess of a 2 day supply of perishable food however there did not appear to be a 7 day supply of non-perishable food. LPA Jensen interviewed the Executive Director who advised that facility is able to transfer food from the Independent Living facility that is adjacent to this facility and under the same management group. Technical assistance was provided with a recommendation to maintain a 7 day food supply on site. Based on the incident reports received over the last quarter the facility has been meeting reporting requirement timelines. LPA Jensen inspected the medication room and observed multiple systems for documenting when a medication was started. Technical assistance was provided with recommendation to consolidate recording efforts. No deficiencies were issued during the course of this visit. An exit interview was conducted and a copy of this report will be emailed.the state’s words, verbatim · CDSS document, Mar 20, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct a case management visit regarding a incident reported to the department on 2/23/2024. LPA Lund was met by Administrator Carlin Robertson and explained the reason for the visit. Census:55 LPA Lund reviewed Resident (R1) Unusual Incident/Injury report dated 2/23/2024 which stated that R1 had a witnessed fall. The facility called hospice and then called 911. R1 was taken to the hospital from 2/23/2024 and returned on 2/25/2024. The facility is doing ½ checks on R1. The facility does have a fall plan in place for R1. R1 will continuing to have hospice which comes twice a week at this time. The facility has scheduled training on how to do proper changing procedures with residents in care. No deficiencies were observed or cited at this time. Exit interview. Copy of report and appeal rights given.the state’s words, verbatim · CDSS document, Mar 4, 2024

Allegation investigated: Staff did not meet the needs of the resident in care.

On 1/8/24 at approximately 2:00pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with the Resident Care Director Caress Brown and explained the purpose of today's visit. The responsible party for Resident 2 (R2) reported that on 10/3/23 R2 was transported to the Emergency Department of the hospital and admitted as a result of suffering from severe hypotension. LPA Jensen reviewed blood pressure logs for R2 from 9/1/23 through 10/3/23. The logs were written to accommodate daily entries. During that period of time a blood pressure reading was taken on only 1 occasion. All other dates state that the resident refused or was out of the facility. There was no evidence to support that facility staff was taking any measures to address the resident's refusal of blood pressure monitoring. LPA Jensen also reviewed the Medication Administration Record (MAR). On 9/24/23 the MAR is recorded with missed dosages for 4 of 8 medications. On 9/28/23 there are 2 medications recorded with missed dosages. On 9/29/23 there are 5 of 8 medications recorded with missed dosages. Substantiated Based on a review of the MAR documenting several missed medication doses and the blood pressure logs documenting resident non-compliance with no action taken by staff, the allegation of "Staff did not meet the needs of the resident in care" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. An exit interview was conducted and a copy of this report and appeal rights were given.the state’s words, verbatim · CDSS document, Jan 8, 2024 · control 27-AS-20231026091826

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 8, 2024

Basic Services 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 LPA Jensen's review of missed medication doses, missed blood pressure readings and a lack of evidence that facility staff was taking actions to address R1's treatment non-compliance. This poses a potential risk to the health, safety and personal rights of residents in carethe state’s words, verbatim · CDSS document, Jan 8, 2024

Plan of correction: The Licensee has conducted in-service training to improve documentation and communication with physician and responsible parties. No further plan of correction is required at this time.

Allegation investigated: Staff mishandled a resident's medications while in care

On 1/8/24 at approximately 2:00pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with the Resident Care Director Caress Brown and explained the purpose of today's visit. LPA Jensen reviewed the Medication Administration Record (MAR) for Resident 1 for September of 2022. It documents that an ACE inhibitor was prescribed and not given from 9/16/22 through 9/25/22. There is no explanation on the MAR as to why the prescription was not administered. According to R1's responsible party, R1 ran out of medication on 9/15/22. It is unclear why the resident missed ten doses of the ACE inhibitor. It is evident that the resident was present at the facility on these dates based on the MAR showing that other prescribed medications were administered therefore the allegation of "staff mishandled a resident's medication while in care" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. An exit interview was conducted and appeal rights given. Substantiatedthe state’s words, verbatim · CDSS document, Jan 8, 2024 · control 27-AS-20231011111327

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 9, 2024

Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on LPA Jensen's review of the MAR, R1 did not receive a prescribed medication for a period of 10 days. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2024

Plan of correction: The Licensee has done a complete reorganization of the medication room and the procedures surrounding medication administration along in-service training. No further plan of correction is required at this time.

Allegation investigated: Staff do not have accurate record keeping for a resident Staff did not address a resident's change in medical condition Staff did not properly report an incident involving a resident

On 1/4/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Regional Director of Operations, Steve Sarine and explained the purpose of today's visit. During the course of the investigation LPA Jensen conducted interviews with 8 staff members and Resident 1 (R1). LPA Jensen reviewed records including but not limited R1's physician report, R1's prescriptions, R1's Needs and Service Plan, R1's Medication Administration Records (MARs), Physician Communication Forms, facility policy and procedure documents, and incident reports from June of 2023 through current. LPA Jensen also inspected R1's private room. Allegation 1 - Staff do not have accurate record keeping for a resident LPA Jensen reviewed the MAR for R1 for October of 2023. R1 received a prescription for a medication on 10/10/23. Continued on LIC 9099C... Substantiated The prescription was written to change the strength of a medication that R1 was currently taking and the current medication was discontinued effective 10/12/23. According to the MAR, R1 did not receive any of the medication that was discontinued from 10/1/23 through 10/12/23. There are entries indicating the medication was not at the facility on 10/1/23, 10/8/23 and 10/12/23 but no explanation for the other dates. LPA Jensen also reviewed the Needs and Service Plan for R1 which was not signed or dated. As a result of the inconsistencies in the MAR and the incomplete Needs and Service Plan the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Allegation 2 - Staff did not address a resident's change in medical condition LPA Jensen reviewed R1's physician report dated 7/13/23. The physician's report states R1 is able to independently transfer to and from bed, is able to dress and groom themselves and has no bladder or bowel impairment. This contradicts the Needs and Service Plan which states R1 requires hands on help with bathing, dressing and grooming. The Needs and Service Plan also states that the resident requires a one person assist with transfer and at times 2 person assist. It further states that R1 requires AM and PM incontinence care. All sections of the Needs and Service Plan state that the Care Team will monitor for changes in condition and conduct a reappraisal as appropriate. The Needs and Service Plan depicts a significantly higher level of need for care than provided for in the physician's report and as such a new physician report's should have been obtained. Based on the comparison between the LIC 602 (Physician's Report) and the Needs and Service Plan the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Allegation 3 - Staff did not properly report an incident involving a resident LPA Jensen reviewed records showing R1 was hospitalized and being treated for a bacterial infection on or around 8/25/23. There was no evidence of an incident report being submitted to the Department for this occurrence and as such the allegation is SUBSTANTIATED. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, an LIC 811 and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 4, 2024 · control 27-AS-20231011111327

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506 · Plan of correction due date: Jan 11, 2024

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident. This requirement was not met as evidenced by: Based on LPA Jensen's review of the incomplete Needs and Service Plan and MAR. This poses a potential risk to the health, safety and personal rights of residents of in care.the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: The Licensee or facility staff agrees to send a plan detailing the actions that have or will be taken to remain in compliance by the Plan of Correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463 · Plan of correction due date: Jan 11, 2024

Reappraisals The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate....The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement was not based on a comparison of the LIC 602 and Needs and Service Plan. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: The Licensee or facility staff agrees to send a plan detailing the actions that have or will be taken to remain in compliance by the Plan of Correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211 · Plan of correction due date: Jan 11, 2024

Reporting Requirements A written report shall be submitted to the licensing agency... within seven days of the occurrence of ...Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by:the state’s words, verbatim · CDSS document, Jan 4, 2024

Plan of correction: The Licensee or facility staff agrees to send a plan detailing the actions that have or will be taken to remain in compliance by the Plan of Correction due date.

Allegation investigated: Staff did not ensure a resident's grooming needs were met Staff did not properly maintain a resident's room Staff allowed a resident to have soiled bedding while in care Staff did not provide adequate supervision to a resident

On 12/26/23 at approximately 12pm, Licensing Program Analyst Maja Jensen arrived at facility unannounced to continue an investigation in to the above listed allegations. LPA Jensen met with Executive Director Kent Mulkey and explained the purpose of today's visit. During the course of the investigation, LPA Jensen conducted interviews, met with residents and inspected resident rooms. Staff did not ensure a resident's grooming needs were met: LPA Jensen interviewed 8 of 8 staff present on this date. 8 of 8 staff gave consistent accounts of facility procedures for resident grooming which aligned with the admission agreement and regulation. LPA Jensen also interacted with residents during the course of 2 site visits and observed all residents to be adequately groomed therefore the allegation of Staff did not ensure a resident's grooming needs were met is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened, the preponderance of evidence does not prove it. Unsubstantiated Staff did not properly maintain a resident's room: LPA Jensen interviewed 8 of 8 staff members present on this date. 8 of 8 staff gave consistent accounts of facility procedures for maintaining resident rooms which aligned with the admission agreement and regulation. LPA Jensen inspected 5 random resident rooms and observed the beds to be made, trash cans emptied, clean linens and clean bathroom surfaces. Based on the interviews conducted teh allegation of staff did not properly maintain a resident's room is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened, the preponderance of evidence does not prove it. Staff allowed a resident to have soiled bedding while in care: LPA Jensen interviewed 8 of 8 staff members present on this date. 8 of 8 staff gave consistent accounts of facility procedures for changing linens which aligned with the admission agreement and regulation. LPA Jensen observed an adequate supply of linens maintained on site to allow for frequent changing of bed sheets. LPA Jensen inspected 5 random resident rooms and observed clean linens in 5 of 5 rooms. Based on the interviews conducted the allegation of staff did not properly maintain a resident's room is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened, the preponderance of evidence does not prove it. Staff did not provide adequate supervision to a resident LPA Jensen interviewed 2 facility residents and 8 staff members. LPA Jensen observed staff interacting with residents during the course of 3 site visits. During LPA Jensen's visits on 10/31/23, 12/4/23 and 12/26/23 staff was observed to be attentive and adequately addressing the resident's needs. The 2 residents interviewed stated they are receiving adequate supervision. During the course of interviews with staff LPA Jensen was advised that staff responds to the call system when activated in less than 5 minutes. Based on the interviews conducted and observations made the allegation of Staff did not provide adequate supervision to a resident is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were provided. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22. Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were given.the state’s words, verbatim · CDSS document, Dec 26, 2023 · control 27-AS-20231011111327

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Dec 26, 2023

Basic Services Basic services shall at a minimum include: ...Personal assistance and care as needed by the resident with those activities of daily living such as dressing, eating, bathing. This requirement was not met as evidenced by: Based on LPA Jensen's record reviews and interviews, the records reviewed were inconsistent with facility policyon showering accordig to staff. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 26, 2023

Plan of correction: The Licensee or facility staff agrees to submit a plan of actions that will or have been taken to stay in compliance with this regulation.

Allegation investigated: Resident being charged for unagreed services.

On 12/26/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigation in to the above listed allegation. LPA Jensen met with Executive Director Kent Mulkey and explained the purpose of today's visit. During the course of the investigation LPA Jensen reviewed the resident file for Resident 1 (R1) and the admission agreement for R1. LPA Jensen also interviewed the Executive Director and the Director of Resident Services. The admission agreement specifies services that are included in the monthly rate as follows: -24 hour supervision -Laundry, room cleaning -Meals -Activities Unfounded The admission agreement also specifies items that are not included as follows: -Medication -Transportation -Briefs for incontinence care -Nutritional Supplements -Personal Toiletries -Health Care Provider Fees -Beauty Salon Services LPA Jensen interviewed the Resident Care Director who advised that typically residents are asked to use Pharmarica for prescription medication as this is the pharmacy that the facility contracts with however someone can request using a different pharmacy if the family brings the medication in or it is mailed directly to the facility. The Resident Care Director indicated that upon admission, the responsible party is asked to sign a consent form for using Pharmarica. LPA Jensen reviewed a consent form signed by the responsible party for R1 for using Pharmarica or Kaiser. LPA Jensen also interviewed 8 of 8 staff members present on this date. All staff members gave consistent accounts of the services provided to residents which aligns with the admission agreement and regulation. As a result of the records reviewed, interviews conducted and LPA observation, the allegation of resident being charged for unagreed services is UNFOUNDED. A finding of UNFOUNDED means that the allegation is false, could not have happened or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 26, 2023 · control 27-AS-20231026091826

Allegation investigated: Facility did not seek medical attention for a resident in its care. Facility failed to report resident's scabies to Licensing. Facility failed to notify responsible party.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with director of resident services Caress Brown and explained the purpose of the visit. This investigation consisted of interviews and record review. LPA Moleski interviewed facility administrator Kent Mulkey, 13 staff members (S1-S13), five residents (R2-R6), and a hospice nurse. Nine of the staff members interviewed were direct care staff, medication technicians, and/or licensed vocational nurses (S4, S5, S6, S7, S9, S10, S11, S12, S13). [continued on 9099-C] Unsubstantiated Among these, S6 said a resident (R1) had scabies. S6 was not sure if R1’s family had been notified, and was not sure if R1 was treated for scabies. In interviews, S4, S5, S9, S10, and S13 said R1 did not have scabies or any rashes. S7 said R1 did not have scabies, but had a rash, and was itchy. S7 was not sure if R1 was being treated for the rash. S11 said R1 did not have scabies, but said R1 had redness on the chest and back. S11 was not sure what the redness was caused by, and was not sure what treatments R1 received for the redness. S12 said R1 was never confirmed to have had scabies, but was itchy. LPA Moleski interviewed five residents (R2-R6). None of the residents remembered R1. LPA Moleski reviewed R1’s file. R1’s Medication Administration Records (MARs) for the months of July through October 2023 did not show any treatments for scabies. R1’s centrally stored medication records dated between 1/4/23 and 10/23/23 did not show any medications that treat scabies. LPA Moleski reviewed a line listing of residents provided by the facility that identified R1 as “asymptomatic.” The line listing states that R1 received a dose of an antiparasitic medication on 8/10/23. Mulkey and S3 said this was a prophylactic treatment. LPA Moleski reviewed progress notes written by facility staff dated between 4/30/23 and 10/25/23 and hospice notes dated between 7/31/23 and 10/24/23. A progress note written by staff on 8/10/23 stated that “Resident received” an antiparasitic medication “for prophylactic tx of scabies.” A progress note written on 10/11/23 states that there were “no skin concerns at this time.” A series of notes written between 10/2/23 and 10/16/23 describe "redness" to R1’s groin and genitalia, which did not cause signs or symptoms of pain or discomfort, according to the notes. Hospice nurses treated the area with barrier cream, according to the notes. A progress note written on 10/20/23 states that there were "no skin issues reported at this time." No further notes describe any skin issues. In interviews, Mulkey, S2, S3, S4, S5, S6, S9, S10, and S11 said residents were treated prophylactically. Mulkey, S2, S5 and S9 said prophylactic treatments were attempted for as many residents as possible, as a precaution. S3 said prophylactic treatments were arranged for asymptomatic residents. S4 and S10 said residents suspected of having scabies were treated. S11 said residents at high risk for scabies or who had unidentified rashes were treated. S12 said only residents who had scabies were treated. [continued on 9099-C] In an interview, a hospice nurse who worked with R1 said R1 did not have scabies. The department has determined the following as it relates to the allegations that the facility did not seek medical attention for a resident in its care, that the facility failed to report a resident's scabies to the Community Care Licensing Division, and that the facility failed to notify responsible party: Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Brown. They also included a Scabies Line List that the facility was instructed to complete with resident and or staff information. On 08/08/23, an unannounced collaborative visit was made to El Rio Memory Care by Licensing Program Analyst, (LPA) Kimberly Viarella, and representatives from Stanislaus County Public Health Department, Zaurina Jones, Public Health Nurse, and Gorlia Xiong, Medical Investigator. The LPA identified herself and her colleagues and asked to speak with the Executive Director. The group explained the purpose of their visit was to provide technical support in addressing the recent scabies outbreak. This visit was informational and educational. The team met with Kent Mulkey, Executive Director, Karan Bassi, Director of Resident Services, and Carlin Robertson, the Campus Business Office Manager. The DRS shared the current practices and procedures that were being implemented to address and prevent the spread of scabies. The SCPHD representatives shared strategies for improving these procedures and offered additional suggestions to assist with eradicating scabies from the facility. These strategies included but were not limited to the following: Separate those who have never been treated / shown symptoms from those who have been treated /shown symptoms as much as possible. On 08/08/23, during the collaborative visit with SCPHD, the DRS Karan Bassi, at the time, informed the group that they were practicing social distancing throughout the community in order to prevent more residents from contracting scabies. This LPA observed an activity taking place in the dining room where more than 12 residents were sitting in a circle shoulder to shoulder less than 6 inches apart. On 8/21/23, Stephen Sarine, Regional Director of Operations (RDO) sent a letter to CCL acknowledging that they had a total of 8 cases, the last dated 8/2/23. According to the LIC 9282 that was submitted to CCL by El Rio Memory Care, their own Emergency Infection Control Plan states the following on page 4. Under section C: 1: Enhanced environmental cleaning and disinfection. Effective environmental cleaning strategies, and the locations where deep cleaning was needed, were not communicated to the PPD There shall be separation and/or cohorting of residents as needed. LPA did not witness any separation / social distancing or cohorting during multiple visits on: 08/03/23, 10/3/23 and 10/18/23. [continued on 9099-C] 2: Isolate residents / use contact precautions until treated. None of the residents were isolated. Treat residents and staff and monitor post treatment for effectiveness. During this investigation, this LPA found multiple instances where residents had to be treated for scabies more than once. One individual was treated more than 3 times since March. Identification of contacts of symptomatic case(s). Questionnaires were never utilized, and visitors and families were not contacted. El Rio Memory Care was not adhering to its own infection control plan as evidenced by the information provided above. … It was encouraged by the team that signage be posted in the lobby regarding potential exposure to scabies upon entering the community. SCPHD also offered to share a template of a letter that could be utilized to share this information with the family members and responsible parties for all the residents in care. The facility did not request this information, and letters were not sent out to responsible parties for residents in care. SCPHD also suggested developing questionnaires to assist in gathering information from those who have visited or who intend to visit the facility. This LPA visited the facility on: 08/08/23, 10/03/23 and 10/18/23 and did not observe any signage regarding the outbreak. Based on interviews with 5 out of 6 responsible parties, El Rio Memory Care did not notify them of their family members’ change of condition requiring scabies treatment. The facility also did not develop or send out any questionnaires.” The allegation that this facility failed to follow its infection control plan has already been substantiated, as described above, and citations have already been issued. No new citations will be issued as a result. The investigation into the allegation that the facility failed to assist with medication administration consisted of record review. LPA Moleski reviewed R1’s file. A doctor’s note written on 8/9/23 prescribed R1 to take six 3 milligram tablets of an antiparasitic medication, and then to take six more tablets one week after the first dose. LPA Moleski reviewed a scabies line listing provided by the facility. According to the line listing, R1 was given a treatment of antiparasitic medication on 8/10/23. The line listing contains a column indicating the dates of second treatments. The author of the line listing wrote “N/A” under this column for R1. Based on a treatment date of 8/10/23, R1 should have received a second dose of the antiparasitic medication on 8/17/23. [continued on 9099-C] LPA Moleski reviewed medication administration records for R1 for the month of August 2023. The antiparasitic medication as described above was not listed on the medication administration records. LPA Moleski reviewed R1’s centrally stored medication records dated between 1/4/23 and 10/23/23. The antiparasitic medication is not listed anywhere in the centrally stored medication records. LPA Moleski reviewed this facility’s plan of operation. The plan of operation’s medication procedures state that: “Every medication brought into the facility should be recorded on the centrally stored medication record…” and that “All continuous, one time and PRN medications are recorded each time they are passed to a resident.” LPA Moleski reviewed progress notes for R1 written by facility staff dated between 4/30/23 and 10/25/23. A note written on 8/10/23 states that “resident received” antiparasitic medication “for prophylactic tx of scabies.” The following note, written on 8/20/23, makes no mention of any second dose of the antiparasitic medication being given to R1. The department has determined the following as it relates to the allegation that the facility failed to assist with medication administration: Based on record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87465(a)(4). An exit interview was held with Brown. Appeal rights and a copy of this report was left with Brown.the state’s words, verbatim · CDSS document, Dec 21, 2023 · control 27-AS-20230825145457

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 22, 2023

"The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on record review, R1 was not given a second dose of antiparasitic medication as ordered by a physician, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Dec 21, 2023

Plan of correction: Licensee agrees to conduct a staff training regarding medication administration and medication record-keeping by the POC due date. Licensee agrees to email LPA Moleski a copy of the training sign-in sheet. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Health Checks

On 12/4/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly health and safety check. LPA Jensen met with Administrator Kent Mulkey and explained the purpose of today's visit. On 8/22/23 a Non-Compliance Conference was held for the following areas of concern: -Reporting Requirements -Assessment and Reassessment - Restricted Health Conditions - Resident on Resident (R:R) Altercation -Outbreak Infestations LPA Jensen reviewed incident reports and verified they are being sent timely. LPA Jensen observed a resident that sustained a recent injury related to a fall and reviewed the incident report for the fall on 11/26/23 which was faxed to the Department on 12/1/23 and was sent timely. LPA Jensen has also received phone calls and incident reports related to resident on resident altercations within the past week. LPA Jensen reviewed pest control documents and verified that the facility has contracted with Clark Pest Control with the last service date being 11/10/23. LPA Jensen reviewed 4 resident files and determined that 2 of 4 resident files contained physician reports that were over 12 months old. 4 of 4 needs and service plans were determined to be current. Deficiencies are being cited form the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies mat result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 4, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jan 4, 2024

Care of Persons with Dementia Each resident with dementia shall have an annual medical assessment as specified in Section 87458...This requirement was not met based on: LPA Jensen's record review of 2 of 4 resident files which did not contain a current LIC 602. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 4, 2023

Plan of correction: The Licensee agrees to update all LIC 602's that are over 12 months old and will email an attestation to LPA Jensen that this has been completed by the POC due date.

Type of visit: Required - 1 Year

On 12/4/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Administrator Kent Mulkey and explained the purpose of today's visit. LPA Jensen toured the exterior of the facility and observed all pathways to be clear of obstruction. The grounds were maintained and contained adequate outdoor furniture and shaded areas for resident outdoor activities. LPA Jensen toured the interior of the facility and observed the facility to be sanitary and odor free. The furniture and equipment were observed to be in good repair. LPA Jensen toured 3 resident rooms. LPA Jensen observed a bottle of wine in 1 room and Lysol disinfectant spray, wound care solution and scissors in another room. The disinfectant spray, wound care solution and scissors appeared to be supplies that were being used by a home health nurse or hospice care worker. All resident rooms were adequately furnished and had adequate lighting. A signal system is available in all resident rooms and was verified to be in good working order. The water temperature in resident rooms was measured at 106 degrees Fahrenheit which is in compliance. The thermostat for the facility was set at 77 degrees which is in compliance. LPA Jensen toured the kitchen and observed lunch being prepared. The kitchen was observed to be sanitary. The refrigerator and freezer temperatures were in compliance. LPA Jensen observed a 2 day supply of perishable food however there was less than a 7 day supply of non-perishable food on site. The Ansul system was last serviced in November of 2023 and is in compliance. There are two dining rooms available for residents. A menu is posted for the month. LPA Jensen tested the carbon monoxide detectors and determined them to be in good working order. The smoke detectors are hard wired. LPA Jensen reviewed the disaster emergency plan and determined it to be in compliance. LPA Jensen reviewed 10 staff files. 1 of 10 files had a first aid certification that expired December of 2022. 1 of 10 files did not have a first aid certification on file. LPA Jensen reviewed 4 resident files. 2 of 4 resident files did not have Physician's report that was completed within the last year. LPA Jensen requested copies of the Infection Control Plan and LIC 500. Technical assistance was provided for the facility to designate an Infection Control Preventionist. The Inspection tool was used during the course this inspection. An exit interview was conducted and a copy of this report, an LIC 811 and appal rights were provided.the state’s words, verbatim · CDSS document, Dec 4, 2023

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility has an outbreak of scabies. Staff did not meet resident's hygiene needs. Staff did not follow protocol when dealing with an infectious outbreak. Facility did not report the rash to family. Facility did not report the rash to licensing.

On 10/27/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver complaint investigation findings regarding the above allegations. LPA identified herself, the purpose of the visit and asked to speak with the Designated Facility Administrator. The LPA met with Kent Mulkey and a brief interview followed. Regarding: Facility has an outbreak of scabies: On 07/27/23 at 4:43 PM, Community Care Licensing (CCL) received a complaint regarding a possible scabies outbreak at El Rio Memory Care. On this same day, LPA Viarella received a phone call from Karan Bassi, the Director of Resident Services (DRS), letting the LPA know that they suspected they might have a resident with scabies. On 08/04/23, the Director sent an LIC 624 stating that they had 4 residents whom they suspected of having scabies, with the first 2 exhibiting symptoms on 07/27/23. On 8/21/23, Stephen Sarine, Regional Director of Operations sent a letter to CCL that acknowledged that they had a total of 8 cases, the last dated 8/2/23. This LPA had inquired during the visit completed on Substantiated 10/03/23 if there were any more residents being treated for scabies and both Karan Bassi, the DRS and Carlin Robertson, the Campus Business Office Manager (CBOM), replied, “No.” On 10/18/23, this LPA visited the facility and during the course of this investigation found that 29 additional residents had been treated for scabies symptoms without CCL or the Stanislaus County Public Health Department (SCPHD) being notified. The standard for the preponderance of evidence has been met and the department finds this allegation SUBSTANTIATED. Regarding: Staff did not follow protocol when dealing with an infectious outbreak. On 7/28/23 CCL received notification from SCPHD that El Rio Memory Care had a resident with a suspected case of scabies on 07/27/23. The resident had a rash, scabs, and blood on their clothing. The resident was prescribed a medication for scabies by their primary care doctor. SCPHD sent an email to El Rio Memory Care with guidance for control, treatment, and disinfection. They also included a Scabies Line List that the facility was instructed to complete with resident and or staff information. On 08/08/23, an unannounced collaborative visit was made to El Rio Memory Care by Licensing Program Analyst, (LPA) Kimberly Viarella, and representatives from Stanislaus County Public Health Department, Zaurina Jones, Public Health Nurse, and Gorlia Xiong, Medical Investigator. The LPA identified herself and her colleagues and asked to speak with the Executive Director. The group explained the purpose of their visit was to provide technical support in addressing the recent scabies outbreak. This visit was informational and educational. The team met with Kent Mulkey, Executive Director, Karan Bassi, Director of Resident Services, and Carlin Robertson, the Campus Business Office Manager. The DRS shared the current practices and procedures that were being implemented to address and prevent the spread of scabies. The SCPHD representatives shared strategies for improving these procedures and offered additional suggestions to assist with eradicating scabies from the facility. These strategies included but were not limited to the following: Separate those who have never been treated / shown symptoms from those who have been treated /shown symptoms as much as possible. On 08/08/23, during the collaborative visit with SCPHD, the DRS Karan Bassi, at the time, informed the group that they were practicing social distancing throughout the community in order to prevent more residents from contracting scabies. This LPA observed an activity taking place in the dining room where more than 12 residents were sitting in a circle shoulder to shoulder less than On 10/018/23 LPA visited the facility and observed a resident (R5) in the main dining room sitting with 3 other residents. R5 was itching and scratching non-stop. LPA brought this to the attention of Kayleen August, the Regional Nurse for Koelsch. LPA suggested checking the resident for scabies. The Regional Nurse confirmed that they had just received a prescription for scabies medication for that R5. R5 was suspected of having scabies and was observed eating in the main dining room with 3 other residents at the table. Vacuum and deep clean. SCPHD recommended that vacuuming all flooring, bedding, and furniture, particularly the furniture in common areas like the dining rooms, would assist in limiting the spread of scabies. On 10/18/23 during an interview with the Physical Plant Director (PPD), Jay Duarte, this LPA learned that furniture and bedding had not been vacuumed and that this information had not been passed along to the PPD. Enhance environmental cleaning procedures. During the interview with the PPD (also in charge of Housekeeping), on 10/18/23, the PPD shared that they had switched to disposable mop and dust heads based on recommendations from public health. This LPA also learned that he had not been informed of the additional 31 residents who had been treated for scabies symptoms (as of 10/18/23) and whose rooms required a deep cleaning. The Physical Plant Director thought the most recent cases had been treated in August of 2023. The PPD had not been instructed to deep clean the rooms of any of the residents who had been treated for scabies since August. 6 inches apart. Communication It was encouraged by the team that signage be posted in the lobby regarding potential exposure to scabies upon entering the community. SCPHD also offered to share a template of a letter that could be utilized to share this information with the family members and responsible parties for all the residents in care. The facility did not request this information, and letters were not sent out to responsible parties for residents in care. SCPHD also suggested developing questionnaires to assist in gathering information from those who have visited or who intend to visit the facility. This LPA visited the facility on: 08/08/23, 10/03/23 and 10/18/23 and did not observe any signage regarding the outbreak. Based on interviews with 5 out of 6 responsible parties, El Rio Memory Care did not notify them of their family members’ change of condition requiring scabies treatment. The facility also did not develop or send out any questionnaires. 6 inches apart. On 8/21/23, Stephen Sarine, Regional Director of Operations (RDO) sent a letter to CCL acknowledging that they had a total of 8 cases, the last dated 8/2/23. According to the LIC 9282 that was submitted to CCL by El Rio Memory Care, their own Emergency Infection Control Plan states the following on page 4. Under section C: 1: Enhanced environmental cleaning and disinfection.Effective environmental cleaning strategies, and the locations where deep cleaning was needed, were not communicated to the PPD There shall be separation and/or cohorting of residents as needed. LPA did not witness any separation / social distancing or cohorting during multiple visits on: 08/03/23, 10/3/23 and 10/18/23. 2: Isolate residents / use contact precautions until treated. None of the residents were isolated. Treat residents and staff and monitor post treatment for effectiveness. During this investigation, this LPA found multiple instances where residents had to be treated for scabies more than once. One individual was treated more than 3 times since March. Identification of contacts of symptomatic case(s). Questionnaires were never utilized, and visitors and families were not contacted. El Rio Memory Care was not adhering to its own infection control plan as evidenced by the information provided above. The standard for the preponderance of evidence has been met and the department finds this allegation SUBSTANTIATED. Regarding: Staff did not meet resident's hygiene needs. Through interviews conducted during the course of this investigation, this LPA learned that scheduled showers are sometimes not completed due to call-outs. 5 out of 5 responsible parties for individuals treated for scabies stated that they noticed their loved ones scratching at a rash and/or scabs and alerted carestaff. During a facility visit on 10/03/23 this LPA inspected the bedding and mattresses in 5 resident bedrooms. 1 had reddish stains on the sheets as well as on the box spring. Pictures were taken for reference. Also related to hygiene, 4 out of 7 responsible parties interviewed stated that they had observed their loved ones in soiled or wet briefs for extended periods of time. Interviews with staff revealed that if there were call -outs it could take 3 to 3 and a ½ hours for one caregiver to complete their rounds. This already exceeds the incontinence check required at the 2-hour mark. The LPA also learned during interviews that if there were callouts, that fewer or sometimes none of the scheduled showers might take place that day. The standard for the preponderance of evidence has been met and the department finds this allegation SUBSTANTIATED. Regarding: Facility did not report rash to licensing. During the course of this investigation, this LPA reviewed the Medication Records for R5 for July and August. There was a handwritten prescription for Permethrin, a drug used to treat scabies, that was administered on 07/14/23. Community Care Licensing was not informed that this resident was treated as early as 7/14/23. The report we received said that the first 2 cases were noted on 7/27/23. El Rio Memory Care failed to meet reporting requirements when they failed to notify Licensing of the change in residents’ conditions and the resulting need for scabies medication. They did not submit LIC 624s alerting CCL to the continued presence of scabies at the facility. By 08/21/23 there were a total of 29 additional residents that had been treated for scabies symptoms. The standard for the preponderance of evidence has been met and the department finds this allegation SUBSTANTIATED. Regarding: Facility did not report rash to families. Based on 5 out of 5 interviews with responsible parties, the facility did not notify them of scabies being present in the facility. In 4 out of 5 cases, the responsible parties informed the facility of the rash and suspected presence of scabies. Some residents have been treated more than once. Families were not notified of additional treatments. R5 was treated for scabies in March of 2023. This LPA reviewed the Medication Record and found additional prescriptions for treatment for R5. A handwritten prescription for Ivermectin was in the MAR and given on 07/31/23. LPA found a third handwritten prescription for Permethrin that was given on 09/22/23 and there was a box on the 28th that appeared to indicate that another dose should have been given at that time, exactly 7 days later. This LPA spoke with the new Director of Resident Services and was informed that R5 had received another Permethrin treatment on 10/21/23. This LPA spoke with R5’s responsible party and they were only aware of the treatment in March and thought R5 might need another as they noticed R5 scratching during their latest visit. The standard for the preponderance of evidence has been met and the department finds this allegation SUBSTANTIATED. Deficiencies for the above substantiated allegations were cited on the LIC 9099D page. A copy of this report was provided along with Appeal Rights. Exit Interview shower logs were completed appropriately. The caregivers would document rashes and bruises. It was up to the nurse performing the actual skin assessments to determine if the rash might be scabies. The standard for the preponderance of evidence has not been met and the department finds this allegation UNSUBSTANTIATED. A property of this report was provided. Exit interview.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 27-AS-20230727163804

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Oct 28, 2023

Reporting Requirements 87211(a)(2) (a) Each licensee... to the licensing agency such reports as ... the following:(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes... The Licensee failed to comply with the above regulations as evidenced by Based on records review, interviews and observation, the licensee failed to report an outbreak of scabies within 24 hrs. CCL was not notified of any of the additional cases of scabies and scabies treatment after 08/02/203. This LPA was informed on 10/18/23 that 29 more residents had been treated.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Licensee has already replaced the DRS and going forward will conduct quarterly audits to ensure the new DRS is complying with policy. Licensee will also update Infection Control Policy to include a detailed Scabies section that incorporates SCHP recommendations. Licensee will submit an attestation that will include a schedule of the Regional Nurse's quarterly inspection and an outline of the new scabies policy by 10/28/23. The final policy will be be completed and submitted to CCL at kimberly.viarella@dss.ca.gov by 10/31/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(9) · Plan of correction due date: Oct 28, 2023

CCR 87465(a)(9) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(9) The licensee shall ensure that infection control practices are maintained in the facility... The Licensee failed to comply with the above regulation: Based on observations, interviews and a records review, the Licensee failed to follow their own infection control plan. Residents suspected of having scabies or showing symptoms of scabies were not separated or isolated. Deep cleanings and vacuuming were not performed. The identification of close contacts was never pursued. This poses/posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Licensee shall conduct training with all staff regarding new infection control policy with an emphasis on scabies prevention. This will be completed by 1122/23. By 10/28/23 Licensee shall submit the date of the all staff training to Kimberly.viarella@dss.ca.gov. Signature sheets of participants will also be included.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 28, 2023

87625 Managed Incontinence (b) In addition to ...Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors ... The Licensee failed to comply with the above regulations as evidenced by: Based on Interviews and observations 6/6 responsible parties stated they had found loved ones in soak adult briefs and/or pants on multiple occasions. 3/5 staff said that incontinent care is not always done as scheduled. This poses/posed an immediate health risk to residents in care during a scabies outbreak.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Licensee will increase staffing to meet the needs of the residents in care. They will supply CCL with the hours work log for the week of 7/27/23 and 10/30/23 along with the coordinating schedules showing an increase in Caregiver / Resident Assistant hours. For the immediate POC, Licensee shall submit the names of new hires to kimberly.viarella@dss.ca.gov by 10/28/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(1) · Plan of correction due date: Oct 28, 2023

87705(b)(1) (b)In addition to ..., Plan of Operation, the plan of operation shall address...with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons. The Licensee failed to comply with the above regulation as evidenced by: The Licensee failed to follow its own plan of operation. and did not notify responsible parties (RP) about scabies. Based on Interviews and records review in 6/6 instances. This posed an immediate, health, safety and/or personal rights risk to those in care and did not assist in containing the spread of scabies.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Licensee shall have all nurses receive training on skin assessment, with emphasis on scabies, to ensure that residents are sent to an MD for an evaluation as soon as scabies symptoms manifest. Licensee shall submit to CCL the date and name of the trainer for these trainings by 10/28/23 Signature sheets for participants will be submitted at a later date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(2) · Plan of correction due date: Oct 28, 2023

87211(a) Each licensee shall furnish to the licensing... as the Department may require: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident... (2) Occurrences, ...24 hours either by telephone... The Licensee failed to comply with the above regulation when: Based on a review of records, R5 was suspected and treated for scabies on 07/14/23. This was not reported to CCL and pose/posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Licensee shall conduct training for all Resident Assistants and Nurses on reporting requirements. Licensee shall submit the dates of these trainings and the name of he facilitator to kimberly.viarella@ccl.ca.gov by 10/27/23. These trainings must be completed by 11/31/23 and signature sheets will be sent to CCL.

Type of visit: Case Management - Deficiencies

On 10/08/2023, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct interviews as a part of a complaint investigation. The LPA identified herself, the reason for the visit and asked to speak with the Designated Facility Administrator. LPA met with Executive Director, Kent Mulkey. A brief interview followed. The LPA observed the residents eating lunch in 2 separate dining rooms. LPA observed that one resident would scratch for 10 -15 seconds, stop for 5 seconds, then begin scratching again. The LPA witnessed this cycle repeat 4 times. The LPA brought it to the attention of the Regional Nurse who confirmed that that a prescription for scabies medication was received on 10/17/23. During the course of the investigation, this LPA learned that 31 additional residents have been suspected of, and treated for, scabies. This information should have been reported to Community Care Licensing as well as the Department of Public Health. Due to time constraints, this case management and the deficiencies associated with today's visit, will be completed at a later date. Exit interview.the state’s words, verbatim · CDSS document, Oct 18, 2023

Allegation investigated: Staff are not ensuring that the facility is free of bed bugs

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to open an complaint for the above allegations. LPA was greeted by Executive Director and explained the reason for the visit. Resident services director was present as well. LPA Lewis gathered documentation. Facility made copies for LPA of the invoices from clark pest control. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit interview conducted. Copy of report given. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 12, 2023 · control 27-AS-20231006160848

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit regarding a incident reported to the department on 10/10/2023. LPA was greeted by Executive Director and explained the reason for the visit. Caress Brown Resident services director was present as well. LPA Lewis gathered documentation. Facility made copies for LPA of and R1'S 602 (physician's report), needs and services plan, complaint intake form, and S1'S employee disciplinary record and personnel change notice. LPA also interviewed executive director. Deficiencies observed or cited at this time see 809D page. Exit interview. Copy of report and appeal rights given.the state’s words, verbatim · CDSS document, Oct 12, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(3) · Plan of correction due date: Oct 12, 2023

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:3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was met as evidenced by statements and witness's who observed staff member rughly handling a resident in the shower. Which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Facility has already compleated staff training, and involved staff have been terminated from the facility.

Type of visit: Case Management - Incident

On 10/03/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced Case Management visit to discuss resident on resident altercations involving R1, specifically LIC 624s dated 07/26/23 and 8/21/23. LPA identified herself, the reason for the visit and asked to speak with the Designated Facility Administrator. LPA proceeded to tour the facility with Carlin Robertson, the Business Office Manager, and Karan Bassi, the Director of Residential Services. LPA observed 18 residents in the Rose Dining Room participating in the Sunshine Club. This LPA also viewed 5 resident rooms where the bedding and mattresses were inspected along with the contents of resident bathrooms. This LPA also observed staff de-escalate 2 distressed residents: the first displayed general anxiety and the second was convinced someone stole her lunch. The LPA reviewed the LIC 602 for R1, and it had not been updated since 03/03/2021. LPA requested R1’s needs and services plan for 07/26/23 as well the plan currently being utilized. In the plan dated 04/28/23, it states that R1 should be getting safety checks 4 times per shift. In the plan dated 8/31/23 it states that R1 should be getting safety checks every hour. With regard to the section titled,” Disposition and Behaviors” there were no changes to the existing plan. It stated, “Occasional intervention to de-escalate” and lists that the resident may be, “Physically disruptive (pushing, biting, throwing, or hitting) and that R1 had a, “History of physical Aggression or violence.” On the final page of the report it scores the needs of the resident by category. For the category Disposition and Behaviors, R1 scored a 6 on the report compiled on 04/2'8/23. After 2 resident on resident altercations, one in which the police were called to the scene, nothing in R1s care plan had changed. LPA requested copies of the EMAR for R1s medications for 07/26/23 as well as what R1 was currently being prescribed. They were almost identical with the only differences being that back in July, R1 was taking more medications for digestive issues and a skin rash. The LPA also reviewed the LIC 602 and it had not been updated since 03/03/2021. Deficiencies were observed and cited during this case management visit and have been cited on the LIC 809 D page. Appeal Rights provided, Exit interview.the state’s words, verbatim · CDSS document, Oct 3, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(5)(A) · Plan of correction due date: Oct 4, 2023

Care, Persons with Dementia 87705(c)(5)(A) (5) Each resident with dementia shall have an annual medical assessment...(A) When any... appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care... This requirement was not met as evidenced by: Dementia care resident has not had a new LIC 602 since 3/3/2021 and the licensee failed to update the needs and services plan of R1 after R1 was involved in 2 separate resident on resident altercations.the state’s words, verbatim · CDSS document, Oct 3, 2023

Plan of correction: Licensee shall identify all the residents requiring updated annual LIC 602's as well as those needed due to change in behavior or condition. Licensee will submit this list to kimberly.viarella@dss.ca.gov by 10/14/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(c)(4) · Plan of correction due date: Oct 4, 2023

Care, Persons with Dementia 87705(c)(4) (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff...resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by: Sufficient staffing would have provided the opportunity for staff to redirect R1 before either of the 2 situations escalated to violence. Per R1's appraisal, R1 "has a history of physical aggression or violence."the state’s words, verbatim · CDSS document, Oct 3, 2023

Plan of correction: The Licensee shall revisit R1's care plan to determine ways to reduce overstimulation by redirecting R1 to a less populated area /activity. Licensee shall submit new care plan to kimberly.viarella@dss.ca.gov by 10/4/2023.