Family Affair Care Home

Allegation investigated: Facility allowed unfingerprinted individual to stay at facility without criminal record clearance

On 11/8/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint visit. LPA met with caregiver, Michael Morales and explained the purpose of today's visit. The assistant administrator, Xue Fei Huang arrived at the facility shortly thereafter and assisted with the rest of the visit. Regarding to the allegation of facility allowed unfingerprinted individual to stay at the facility without criminal record clearance, the reporting party received an IHSS (In Home Support Services) application for an individual who is currently residing at the facility as a renter and not a resident and in order for IHSS to process the application, they reached out to CCLD for some guidance because it is uncommon for their applicants to be residing at a licensed facility versus a private residence. After received this inquiring, CCLD initiated this complaint to ensure the facility is in compliance with criminal record clearance. During today's visit, LPA interviewed facility staff, assistant administrator, administrator via phone, greeted the individual-in- question and toured the facility. Unfounded According to the assistant administrator and the administrator, this individual - in -question (R1) was admitted to the facility in April 2023 from Eden Hospital/Sutter Health as a resident and Sutter Health was paying for his/her stay. However, Sutter Health stopped their payment on July 16, 2023 and R1 and R1's responsible party were not able to pay for the monthly fee, therefore, an agreement was reached that R1 would only be responsible to pay for the room and R1's responsible party would be responsible to provide the Activities Of Daily Living. Based on the documents provided by the facility, LPA observed facility has obtained adequate documents for R1 as a resident. After the investigation, this allegation is deemed to be unfounded. Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis. Report was discussed and a copy of this report is provided.the state’s words, verbatim · CDSS document, Nov 8, 2023 · control 14-AS-20231102153516

Allegation investigated: -Illegal eviction

On March 17, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Leslie Hui and explained the purpose of the visit. Regarding the allegation of illegal eviction, according to the reporting party, On February 15, 2023, Resident #1 (R1) was sent to the hospital by the facility staff for reason of “pneumonia.” The reporting party indicated the hospital wanted to release R1 back to the facility the same day, however facility stopped answering the hospital’s phone calls and locked the facility doors. Furthermore, R1 had to spend the night at the hospital. During the investigation, LPA reviewed R1’s file, conducted interviews, reviewed R1’s discharge notes from 2/15/23-2/16/23. According to the administrator, the facility did not want to take the resident back because the administrator received two phone calls (name and position was unknown according to administrator) indicating that R1 had pneumonia, however later in the day the administrator received another call, (name and position was unknown as well according to administrator) indicated R1 did not have pneumonia. According to the administrator, she was unsure what to believe and wanted to contact R1’s responsible party to get his/her opinion prior to taking R1 back. In addition, the administrator stated that when R1 came back to the facility, both her and another staff were helping another resident for about 30 minutes and by the time someone got to the door, there was no one there. (CONT. TO 9099C) Substantiated Based on the interviews conducted, R1 indicated that the Co-Administrator told him/her to fake his/her symptoms. When taken to the hospital, R1 confirmed he/she did not have pneumonia. In addition, according to the on-call nurse on 2/15/23, the hospital called the facility notifying them of R1’s discharge, however the Administrator was refusing to take R1 back. The On-Call nurse then called the facility to notify them that R1 does not have pneumonia. According to the hospital staff interviewed, the Case Manager and the Emergency Department Nurse call the Administrator as well to confirm that R1 did not have pneumonia, is stable and is going to get discharged from the hospital. Furthermore, when R1 was taken back to the facility, the facility lights were off, the doors were locked, and no one was opening the door. Based on the discharge documents reviewed, R1 did not have any signs of pneumonia both clinically, on x-rays, and on exams. In addition, discharge documents indicated, when R1 was returned to the facility, the facility shut off it's lights and locked the doors after noticing that EMS returned with the R1. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated as the facility administrator acknowledged that she refused to allow R1 to return back to the facility until R1's responsible party assessed R1 prior to returning. In addition, it was indicated that the administrator did not assess the R1 when at the hospital and did not reassess R1 when he/she returned back to the facility. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator, Leslie Hui and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Mar 17, 2023 · control 14-AS-20230216132540

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Mar 24, 2023

87463 Reappraisals: (a) ...The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to... Violation of this regulation is not met as evidenced by: Based on interviews conducted and information collection, the facility administrator acknowledged that she refused to take R1 back to the community because the hospital did not properly assess her, however instead of administrator going to assess her, the administrator called R1's responsible party to assess R1 prior to discharge. In addition, the administrator acknowledged she did not reassess R1 when R1 was in the hospital or when R1 returned back to the community.the state’s words, verbatim · CDSS document, Mar 17, 2023

Plan of correction: Facility administrator to review CCR 87463 and submit acknowledgement to LPA. In addition, administrator to submit a written plan to address concerns regarding what facility can do if hospital does not properly assess resident prior to discharge.

Type of visit: Case Management - Deficiencies

On March 17, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced conducted an unannounced case management visit in relation to complaint control #: 14-AS-20230216132540. LPA met with Administrator, Leslie Hui and explained the purpose of the visit. During the investigation of complaint control #14-AS-20230216132540, it was indicated that Resident #1 (R1) went to the hospital on 2/15/23 for pneumonia. On 2/21/23, during a complaint investigation, LPA asked Administrator if she submitted a copy of the Incident Report to CCL. According to the Administrator, she indicated she was unaware that an Incident Report needed to be submitted to CCL. During the same complaint investigation, it was indicated that the Co-Administrator, Xuefei Huang told R1 to lie about his/her symptoms to be taken to the hospital. When LPA addressed this to the Administrator and Co-Administrator, and she denied this statement and indicated that R1 was experiencing symptoms. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator and a copy is provided with appeals rights.the state’s words, verbatim · CDSS document, Mar 17, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 24, 2023

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... Violation of this regulation is evidenced by: Based on the interviews conducted an information collected, the facility failed to submit an incident report for an incident that occurred on 2/15/23. In addition the facility adminsitrator acknowledged that she was unaware that a report had to be submitted to CCL.the state’s words, verbatim · CDSS document, Mar 17, 2023

Plan of correction: Facility administrator to read CCR 87211 Reporting Requirements and submit acknowledgement of the regulation to LPA by due date.

Type of visit: Required - 1 Year

On February 21, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA met with Caregiver, Genalyn David and Administrator, Hui Leslie joined shortly thereafter. LPA explained the purpose of the visit. Upon arrival, LPA observed the COVID signage posted at the front entrance. LPA was screened at entry point and Caregiver was able to provide screening log documentation for visitors, residents and staff. LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a double story home. LPA toured the first floor and observed 7 resident bedrooms; two of which are shared rooms with beds 6ft apart. LPA observed 3 full bathrooms and 2 half bathrooms. Bathrooms were equipped with liquid soap, paper towels and a trash can with a fitted lid. LPA advised caregiver to remove bar soaps from communal bathrooms. LPA observed extra linen present and first aid kit to be completed. LPA observed medication cabinet to be unlocked and accessible to residents. Caregiver locked the medication cabinet in LPA's presence. LPA observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. Overall the facility is odor-free and in good repair. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable, however LPA observed facility fridge to have expired milk. Sharps drawer was observed to be locked, however LPA observed a knife on the kitchen counter-top and no staff present. Expired milk was thrown away during the visit and caregiver put the knife in the locked cabinet. LPA toured the garage and observed chemicals and toxins cabinet to be unlocked. Cabinet was immediately locked by caregiver. In addition, LPA observed washer and dryer to be in good working condition and observed extra food supply present. 30-day PPE supply was present. (CONT. TO 809C) During the visit, LPA observed Staff 1 (S1) to not be fingerprint cleared and/or associated to the facility. According to the administrator, S1 will be going to get fingerprinted today. LPA toured second floor and observed 2 caregiver rooms and a full bathroom to be clean. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. LPA requests the following forms to be submitted to CCLD by 2/28/23: -LIC308 Designation of Administrator Organization -LIC500 Personnel Report -LIC610D Emergency Disaster Plan -Administrator Certificate Report is reviewed with Administrator and a copy is provided with appeals rights.the state’s words, verbatim · CDSS document, Feb 21, 2023

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Feb 22, 2023

87355 Criminal Record Clearance:(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or... Violation of this regulation is not met as evidenced by: During the visit, LPA observed S1 cleaning the facility however he was not fingerprint cleared and/or associated. In addition, Administrator indicated that S1 has an appointment to get fingerprinted on 2/21/23.the state’s words, verbatim · CDSS document, Feb 21, 2023

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Feb 22, 2023

87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... Violation of this regulation is not met as evidenced by: During the visit, LPA observed the medication cabinet to be unlocked and accessible which poses an immediate health and safety concern to residents in care.the state’s words, verbatim · CDSS document, Feb 21, 2023

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Feb 22, 2023

87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons...which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Violation of this regulation is not met as evidenced by: During the visit, LPA observed the chemicals and toxins cabinet located in the garage to be unlocked and inaccessible to residents which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 21, 2023

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Feb 22, 2023

87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives... and other items that could constitute a danger to the resident(s). Violation of this regulation is not met as evidenced by: During the visit, although LPA observed the knives locked and stored away from residents, LPA observed a knife on the kitchen counter top while a staff member was not presentthe state’s words, verbatim · CDSS document, Feb 21, 2023

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Feb 22, 2023

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (8) All food shall be of good quality... Violation of this regulation is not met as evidenced by: During the visit, LPA observed the facility fridge to have gallons of expired milk which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 21, 2023

Type of visit: Case Management - Other

In response to application for capacity increase from 6 to 10 beds, LPA Jeung inspected physical plant and observed residents. Fire clearance has been approved for 7 non-ambulatory and 3 bedridden elderly persons. Staff reside on the upper level of this 2 story home; there are 2 beds in each room. According to administrator, Ms. Leslie, staff are awake at night. There is a full bathroom on the 2nd floor for staff. On the ground level, there are 6 bedrooms and 4 bathrooms; 3 bathrooms are designated for residents and one is for staff use. Two rooms were constructed on the east side of house. A partial wall has been erected dividing the large rear bedroom on the west side of the house; there is an 8 inch open space above the wall, so the rooms are NOT fully enclosed as bedrooms, as required by San Bruno City Planning Dept. Deficiencies of the California Code of Regulations, Title 22 are observed and cited on a following page> The following forms are requested to be submitted to CCLD by 10/31/22: - Personnel Report (LIC500) - Emergency Disaster Plan (LIC610E)-- must be maintained in facility - Bedridden Plan of Operation Approval of capacity increase is pending receipt of the above referenced items and numbers added to client rooms. Bedrooms are not identified by number. Numbers to be added to bedroom doors for identification. The bedroom with the partial wall can be numbered and designated "A" and "B". Ms. Leslie is advised that an emergency signal system is required if staff are NOT awake at night.the state’s words, verbatim · CDSS document, Oct 24, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Oct 24, 2022

POSTURAL SUPPORTS Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This violation exists based on observation of full bed rails on bed of client #4 in shared room beyond living room. Client is not on hospice care. Licensee failed to ensure that full bed rails are NOT used, which poses an immediate health, safety or personal rights risk for clients in care.the state’s words, verbatim · CDSS document, Oct 24, 2022

Plan of correction: Full bed rail was reduced to half bed rail in LPA's presence and positione at the head of the bed. Deficiency corrected and cleared

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(2) · Plan of correction due date: Oct 31, 2022

PERSONAL RIGHTS Residents in all RCFEs shall have the following personal right: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met, as there is no COVID screening or temperature check upon arrival at facility for visitors. Visitor log does not include date, contact information, confirmation that COVID symptoms are absent, and temp check. Licensee failed to ensure that visitors are properly COVID screened, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 24, 2022

Plan of correction: Visitor log will be revised to include date, time, contact information, confirmation that COVID symptoms are absent, and temp check. Proof of correction to be sent to CCLD BY DUE DATE

Allegation investigated: Staff do not wear masks Facility did not provide a bedroom for resident Facility did not assist resident with self-administration of medication as prescribed Staff did not regularly observe resident for change in condition

On 5/10/22, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20211207111332. LPA Han met with Lead Caregiver, Ganalyn David and explained the purpose of the visit. LPA Han also spoke to administrator, Leslie Hui over the phone and explained the purpose of today's visit. Regarding allegation of- staff do not wear masks, during the 10-day initial visit on 12/14/2021, LPA was greeted by staff #1 (S1) at the entrance who was not wearing a mask and after LPA's reminder, S1 immediately went to get a mask and put it on. Based on observation, this allegation is substantiated. Regarding to allegation of- facility did not provide a bedroom for resident, during the initial 10-day visit, LPA observed two beds in the big/living room, positioned in "L" shape. According to the Staff #2 (S2), the facility has sufficient number of bedrooms for all the residents. However the 2 female residents who were supposed to be sharing a room did not get along so in order to separate them, the facility empty a bedroom that was occupied by 2 male residents and moved them into the big/living room. Also, S2 stated that the 2 male residents would eventually go back to their bedroom when one of the female residents goes home but S2 did not have the discharge date for this female resident. Based on observation and interview during the course of investigation, this allegation is substantiated as the facility violated the Personal Accommodations and Services of the 2 male residents to accommodate the 2 female residents. Substantiated Regarding the allegation of- facility did not assist resident with self-administration of medication as prescribed, the reporting party stated that the facility failed to assist Resident #1 (R1) with pain medication as ordered by the physician. According to Staff #3 (S3), R1 asked for pain medication in the middle of the night, and S3 did not feel comfortable of given it to R1 so S3 asked R1 to wait for S2 to give it in the morning as S2 was sleeping at the time. According to R1's hospital medical record, R1 has an order for Acetaminophen (Tylenol) every 6 hours as needed for pain. During an interview with S2, S2 stated that facility did not give R1 any pain medication during the time of R1's stay. Based on interviews and record review during the course of investigation, this allegation is substantiated as the facility did not give R1's pain medication as prescribed by the physician. Regarding to allegation of- staff did not regularly observe resident for change in condition, the complainant reported that the facility did not observe and check R1's blood sugar level as ordered by the physician which resulted R1's blood sugar rose to 282. According to Administrator, the facility did not conduct a pre-admission appraisal of R1 prior to R1's admission, therefore, the facility was not aware that R1 required blood sugar checks every 4 hours and then insulin injections accordingly until R1's responsible party informed the facility of such needs after R1's admission. In addition, the facility failed to conduct a pre-admission appraisal to ensure R1 is suitable for the facility. Furthermore, during the course of investigation, LPA observed injections and blood sugar finger stick checks for the resident who was not capable of performing it by themselves were administered by a facility staff who was not a skilled professional . These deficiencies will be cited on LIC809 and LIC809D. Based on R1's hospital documentation provided, R1 has Insulin Lispro Sliding scale 6 times a day with specific times and physician's order for insulin injection but the facility was not aware of these orders as the facility failed to conduct a pre-admission appraisal prior to R1's admission. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with administrator(over the phone), caregiver and Appeal Rights provided. A copy is provided. Regarding allegation of facility is malodorous- during the initial inspection, the staff provided a tour of the resident's rooms, living room, the big room, kitchen, dining room and the bathrooms. LPA observed facility was cleaned, tidy and odorless. According to the facility staff, they clean the facility every day and the residents also stated that the facility is cleaned and their rooms are being cleaned daily. Based on interviews and observation during the course of investigation, this allegation is deemed to be unsubstantiated. Regarding allegation of - facility did not ensure resident's medication was maintained at the facility, the Reporting Party stated that R1 brought pain medication to the facility upon admission but the facility could not find it during R1's discharge. LPA interviewed staff #2 (S2) and they denied the allegation and stated that upon R1's discharge, all the medication was taken by the Responsible Party who was present at the time. In addition, LPA observed the medication storage cabinet and did not find any medications with R1's name on it. Furthermore, LPA interviewed the other residents regarding to their experience of medication storage, and they stated they have not experienced their medication being missing. Based on interviews during the investigation, this allegation is deemed to be unsubstantiated. Regarding allegation of- Staff speaks inappropriately to resident, the Reporting Party stated that facility staff yelled at R1 when R1 asked for assistance. The facility staff denied the allegation and stated they never yelled at R1 and other residents. According to S3, R1 was ringing the bell very loudly for assistance during the night and S3 was very close to R1 so S3 asked R1 to not ring the bell so loudly as S3 did not want the sound of the bell to wake up other residents. As part of the investigation, LPA interviewed 2 others residents and both of them stated that the facility staff never yelled at them, they are attentive to their needs and respectful while speaking to them. Based on interviews during the investigation, this allegation is deemed to be unsubstantiated. Although the allegations may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED. Regarding allegation of- staff do not ensure that staff and residents are social distanced, the reporting party stated it was not staff who were not socially distanced from the resident, rather it was resident to resident as R1's bed was attached to resident #2 (R2)'s bed in the big room. Based on the above clarification information provided by the reporting party, this allegation is deemed to be unfounded. In addition, During the 10-day initial complaint visit, LPA observed R1 and R2's beds were positioned in a "L" shape and there were a table in between the 2 beds. Although the beds were not 6" apart, the facility did follow the head - to - toe orientation. Based on this investigation, this complaint allegations are determined to be unfounded, meaning that the allegation could not have happened and/or is without a reasonable basis. This report is reviewed and discussed with administrator (over the phone) and lead caregiver. A copy is provided.the state’s words, verbatim · CDSS document, May 10, 2022 · control 14-AS-20211207111332

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 12, 2022

87468.1 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:(2) To be accorded safe, healthful... This requirement is not met as evidenced by: during the 10-day initial complaint visit, LPA observed staff #1 was not wearing any face covering which posed an immediate health and safety risks to resident in care.the state’s words, verbatim · CDSS document, May 10, 2022

Plan of correction: The administrator and/or designee shall provide in-services to facility staff on the importance of following the mandated mask protocol. The administrator and/or designee will provide a copy of the sign-in records to CCL by 5/12/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 12, 2022

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical,...When changes such as...physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: the facility failed to observe R1's blood sugar level which posed an immediate health and safety risks to resident in care.the state’s words, verbatim · CDSS document, May 10, 2022

Plan of correction: The administrator will review this regulation and provide a copy of a signed statement acknowledging of the review and understanding to CCL by 5/12/22. The administrator will provide in-services to staff on the importance of Observation of the Resident and provide a copy of the education sign-in record to CCL by 5/12/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 12, 2022

87465 Incidental Medical and Dental Care...(a)A plan for incidental medical... shall be developed by each facility..(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: the facility failed to assist R1's pain medication during the night upon R1's request as prescribed by R1's physician posed an immediate health and safety risks to resident in care.the state’s words, verbatim · CDSS document, May 10, 2022

Plan of correction: The administrator/Licensee will validate all staff are trained on assisting residents with their prescribed medication. Afterwards, the administrator or the licensee will submit a statement to CCL of such validation by 5/12/22. In addition, the administrator and/or designee will provided in-service to facility staff on assisting resident's medication at all times as prescribed and provide a copy of the facility staff sign-in record to CCL by 5/12/22/

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a)(2)(B) · Plan of correction due date: May 12, 2022

87307 Personal Accommodations and Services..(a)Living accommodations...The facility shall be large enough to provide comfortable living accommodations and privacy for the residents...(2)Resident bedrooms shall be provided which meet..(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This requirement was not met as evidenced by: the facility moved 2 male residents who were sharing a room into the living room to accommodate a female resident who did not get along with her roommate which posed an immediate health and safety risks to resident in care.the state’s words, verbatim · CDSS document, May 10, 2022

Plan of correction: The administrator or licensee should review this regulation and provide a statement of acknowledgment to CCL by 5/12/22. In addition, the administrator shall develop a plan to avoid this situation from happening again and provide a copy of the plan to CCL by 5/12/22.

The state marks this report as 11 pages; the online copy we transcribed has 10. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 5/10/2022, Licensing Program Analyst, (LPA) Murial Han conducted an unannounced case management visit on behalf of LPA, Audrey Jeung regarding facility's request of increasing total capacity from 6 to 10. LPA was greeted by lead caregiver, Gina David who called administrator, Leslie (Carol) Hui informing of LPA's visit. LPA explained the purpose of the visit to lead caregiver and administrator. During today's visit, lead caregiver provided a facility tour, LPA observed construction workers on site, LPA reviewed and compared the old and the new facility sketch and requested for the following documents to be submitted to LPA Jeung by 5/12/22: - A copy of the Conditional Use Permit - Name and contact information of the fire inspector - Proof of notification to residents, responsible party(s) and CCL regarding the project of increasing capacity - A check of $25 made to Department of Social Services for the change of capacity - A copy of the approved building permit This report is reviewed and discussed with administrator via phone and lead caregiver. A copy is provided.the state’s words, verbatim · CDSS document, May 10, 2022

Type of visit: Case Management - Other

On 5/10/22, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20211207111332. LPA Han met with Lead Caregiver, Ganalyn and explained the purpose of the visit. LPA Han also spoke to administrator, Leslie Hui over the phone explaining the purpose of today's visit. During the investigation of the above complaint, the administrator stated that the facility did not conduct a pre-admission appraisal prior to resident #1 (R1)'s admission. Therefore, the facility was not aware of R1's blood sugar management that was required and prescribed by R1's physician. Based on the complaint investigation, the facility failed to preform a pre-admission on R1 to ensure R1 is suitable for the facility. During the investigation of the above complaint, the reporting party stated that R1 was not able to administer insulin, therefore, staff #1 (S1) would be administering it for R1 but the reporting party was not sure if S1 is qualified to do that. As part of the investigation, LPA interviewed administrator who stated that facility has a phlebotomist who is certified to administer injections would go to the facility 2x/day administering insulin injections for resident(s). LPA interviewed resident #2 (R2) regarding to the facility's protocol on administering injections and R2 stated that S1 administered it on a daily basis as R2 was not physically capable of doing it. During the 2nd interview with administrator, the administrator confirmed that S1 was not a skilled professional nor a phlebotomist, and he/she just learned that S1 was administering injections as the phlebotomist was too busy to do it. Based on the complaint investigation, the facility failed to ensure injections are administered by the resident or by an appropriately skilled professional. Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator. A copy of this report and the Appeal Rights is provided.the state’s words, verbatim · CDSS document, May 10, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(a) · Plan of correction due date: May 12, 2022

87629 Injections..(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular,..intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This requirement is not met as evidenced by: R2 was not able to administer injections and injections were administered by S1 who was not an appropriately skilled professional which posed an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, May 10, 2022

Plan of correction: Administrator and/or licensee will develop a plan to be in compliance with this regulation and such plan shall be submitted to CCL by 5/12/22. In addition, the administrator and/or the licensee will review this regulation, and submit a statement of acknowledgment his/her review to CCL by 5/12/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87457(c) · Plan of correction due date: May 12, 2022

87457 Pre-Admission Appraisal - General..(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal ... This requirement is not met as evidenced by: the facility did not conduct a pre-admission appraisal of R1 which resulted the facility not able to meet R1's blood sugar management needs which posed an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, May 10, 2022

Plan of correction: The administrator will review this regulation and submit a written statement of compliance pertaining to the regulation to CCL by 5/12/22.