Fam Care Homes

Type of visit: Required - 1 Year

On 11/2/2023 at 1:00pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Administrator, Chioma "Abigail: Okpara, and explained the purpose of the visit. The Administrator holds a certificate 6054129740 which expires on 10/30/2023. The facility’s fire clearance is approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) bedrooms and three (3) bathrooms. One (1) bedroom is occupied by staff. No bodies of water was observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/09/2022. Emergency Disaster Plan was last posted on 09/04/2023. First aid kit was observed to be complete. Fire drill was last conducted on 08/01/2023. Continued on LIC809. Continued from LIC809. LPA reviewed two (2) staff files both have first aid and CPR certification. LPA also reviewed all five (5) residents' files which were current and complete. LPA observed the following deficiencies: At 2:00pm, LPA observed broken window in bathroom located in activity room. LPA requested the following documents to be submitted to CCLD by 11/9/2023. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (last page) Liability Insurance Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due date, and any repeat violations within 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report provided.the state’s words, verbatim · CDSS document, Nov 2, 2023

Allegation investigated: Staff is restricting resident from having visitors

On 6/30/2023 at 12:15pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPA met with Abigail "Chioma" Okpara, Administrator and explained the reason for the visit. During the course of the investigation LPA interviewed Staff, Reporting Party (RP), and a Resident 1 (R1). LPA requested the following documents be emailed to CCL by 7/3/2023: admission agreement, sign-in sheet, house rules, client roster, LIC500, physician's report, and email correspondence between family and facility. During interview the RP it was stated that the facility is restricting times for visits. R1 was admitted into the facility on 6/26/2023. R1 stated during interview that RP was told he Continued on LIC9099C. Unsubstantiated Continued from LIC9099. only had 2 hours to visit because of the time he arrived at the facility. Both Staff stated during interview that the facility does not restrict visits and that visiting hours are from 10am to 6pm. LPA reviewed house rules which indicated the visiting hours are listed as staff stated. Review of sign-in sheet indicated R1's family have visited twice since admission. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jun 30, 2023 · control 15-AS-20230628102808

Allegation investigated: Licensee is refusing Ombudsman to conduct facility visits.

On 4/21/2023 at 9:30AM, Licensing Program Analysts (LPAs), L. Hall and L. Alexander arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPA met with Abigail Okpara, Administrator and explained the reason for the visit. During the course of the investigation LPA interviewed Administrator, RP, and a witness via email. LPA also collected facility's sign-in sheets. During interview the witness stated the ombudsman was not let entry into the facility on 8/5/2022. LPA reviewed sign-in sheet and observered signatures from ombudsmans on 4/8/22, 7/25/22, and 3/7/2023. S1 stated that she understands the ombudsman has entry into the facility at any time and she will continue to let them inside. Continued on LIC9099C. Unsubstantiated Continued from LIC9099. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Apr 21, 2023 · control 15-AS-20230418130210

Allegation investigated: Resident became severely dehydrated and developed a pressure injury while in care. Facility not ensuring resident is fed. Resident's grooming needs are not being met.

On 2/2/2023 at 09:55AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Caregiver, Fitzgerald Ohale and explained the purpose of the visit. Administrator, Abigail Okpara arrived at 10:15AM. During the course of the investigation, the Department conducted interviews with staff, Reporting Party (RP), obtained and reviewed records. On the above allegation, Resident became severely dehydrated while in care and developed a pressure wound, based on doctors’ notes dated 10/11/2022, there was insufficient evidence to show R1 being dehydrated or any signs of pressure wounds. Staff were also interviewed and denied R1 being dehydrated or complaining about pressure wounds. R1 no longer resides at facility and was not able to be interviewed. Based on the investigation the above allegations are unsubstantiated. Continued on LIC9099C. Unsubstantiated Continued from LIC9099. LPA interviewed staff, obtained and reviewed menus, and conducted a complete food inspection. R1 no longer there, however, R1 lived at the facility over 2 years. On the allegation facility not ensuring resident is fed, S1 stated during interview that on 11/10/2022, the day R1 was taken to the hospital, the ambulance came early in the morning and R1 had not eaten breakfast. S1 also stated R1 was able to eat finger foods but required some assistance with feeding. During record review LPA reviewed physician’s report that indicated R1 was able to feed himself. On the allegation Resident’s grooming needs are not being met. S1 stated R1 had a licensed person coming in to cut his nails, but the person stopped coming and R1’s family started cutting his nails. During record review of progress notes dated 8/1/2022, it indicated that R1’s skin was cut after nail cutting conducted by R1’s family. S1 contacted Kaiser to send a licensed person but facility never received a referral. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Feb 2, 2023 · control 15-AS-20221121113711

Type of visit: Case Management - Health Checks

On 11/22/20222 at 10:25AM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint. LPAs met with Chioma "Abigail" Okpara, Administrator and explained the reason for the visit. Upon arrival, LPAs observed total of two (2) staff and one two (2) residents in the facility. LPAs was informed that one (1) resident was in the hospital and one (1) resident has been transferred to a skilled nursing and is not returning. During the health and safety check, LPAs toured the building with Administrator including but not limited to common areas, bathrooms, and bedrooms. Facility is noted to be clean and in good repair and residents in care appear to be safe. There are no imminent health/safety concerns on today's date. LPAs observed the following deficiencies: - Resident files for R1, R2, R3, and R4 were incomplete. - Administrator did not submit an incident report for R1 and R2 The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report, LIC9098, and appeal rights providedthe state’s words, verbatim · CDSS document, Nov 22, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Nov 29, 2022

87506 Resident Records (a) The licensee shall ensure that a... complete, and current record is maintained for each resident... This requirement was not met as evidence by: Based on LPAs record review and observation, Licensee did not comply with the section cited above in having residents records complete, which poses a potential health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Nov 22, 2022

Plan of correction: Administrator agreed to review Regulation 87506 Resident Records and submit a self-certification that the regulation has been reviewed and Administrator will abide by the regulation going forward by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Nov 29, 2022

87211 (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events... This requirement was not met as evidence by: Based on LPAs record review and observation, the licensee did not comply with the section cited above, in reporting incident to CCLD, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 22, 2022

Plan of correction: Administrator agreed to review Regulation 87211 Reporting Requirements and submit a self-certification, along with LIC624 for R1 and R2, that the regulation has been reviewed and Administrator will abide by . the regulation going forward by the POC date.

Type of visit: Required - 1 Year

On 10/27/2022 at 3:15PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Chioma "Abagail" Okpara, Administrator, and explained the purpose of the visit. Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 130.5 degrees Fahrenheit. Fire extinguisher last serviced on 6/14/2022. LPA observed a minimum of 7-day non-perishables and 2-day perishables foods. During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the infection control plan on file. LPA observed food and paper supplies are sufficient. No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 27, 2022

Allegation investigated: Facility illegally evicted resident

On 6/23/2022 at 2:12PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegation above. LPA met with Administrator, Abigail Okpara. During the investigation, LPA interviewed 1 staff and 3 witnesses. LPA obtained and reviewed R1's physician's report, discharge documents, medication list, and correspondence to CCLD. LPA reviewed R1's file and observed facility was missing documents including: admission's agreement, pre-placement appraisal, and emergency information. Interview with staff indicated that R1 was sent out on 1/17/2022 to the emergency due to pain. S1 stated that R1 was not evicted and can come back to the facility. (Continue on LIC9099C...) Unsubstantiated Interview with witnesses revealed that S1 consulted with R1's doctor and made an effort to help with R1's chronic back pain. W2 stated that S1 was following Kaiser's instructions to bring R1 to the emergency room and Kaiser will find alternative placement for R1. W2 stated that R1's doctor and Kaiser was aware that R1 will be relocated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jun 23, 2022 · control 15-AS-20220118102109

Type of visit: Case Management - Other

On 6/23/2022 at 2:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Administrator, Abigail Okpara. While LPA was conducting a complaint investigation to deliver findings, the following deficiency was observed. During complaint investigation, facility did not have admission agreement, pre-placement appraisal, and emergency contact information for R1 prior to admitting R1 to the facility. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 23, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b) · Plan of correction due date: Jul 7, 2022

Resident Records Each resident’s record shall contain at least the following information: This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by having incomplete file for R1 which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Jun 23, 2022

Plan of correction: Administrator has agreed to review all current resident files for completion and submit self-certification to CCLD by POC date.

Allegation investigated: Residents are not offered activities.

On 09/29/2021 at 10:30AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the above allegation. LPA met with Chioma Okpara, Administrator, and explained the reason for the visit. During the course of the investigation, LPAs conducted interviews with staff, residents, Reporting Party (RP), obtained and reviewed documents. Interviews and document review indicated that there were not activities being offered to residents. Staff was not able to provide an activity schedule. LPAs observed four (4) four of five (5) residents watching television. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D. Exit interview conducted. A copy of appeal rights and this report provided. Substantiated On the allegation facility denied resident visitation. LPAs interview with RP stated that RP went to pick up R1 twice. LPAs reviewed visitation policy and sign-in sheet (3/27/21-5/30/21). Sign-in sheet indicated R1 had a visitors several times, therefore R1 was not denied visitation. On the allegation staff speak inappropriately to residents in care. LPAs interviewed three (3) out of five (5) residents. Residents stated staff is polite and helpful. None of the staff have spoken inappropriately to residents and residents have not seen that occur to any of the other residents. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conduct and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 29, 2021 · control 15-AS-20210519112038

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(i) · Plan of correction due date: Oct 6, 2021

87219 (i) Facilities shall provide... equipment and supplies... including... newspapers, magazines... Special equipment and supplies... This requirement was not met as evidence by: Based on LPA's observation and interviews, Licensee did not comply with the section cited above, which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2021

Plan of correction: Administrator agreed to supply residents with games, newspapers and other activities. During visit LPA observed games and books. Deficiency cleared during visit.

Type of visit: Required - 1 Year

On 09/29/2021 at 09:30AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Title, Chioma Okpara, Administrator and explained the purpose of the visit. Upon entry, LPA's temperature was not checked. LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, garbage can with a lid, and hand washing posters. During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food, and paper supplies are sufficient. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Sep 29, 2021