Garden House Morro Bay

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) De Leon conducted a Case Management- deficiency visit to the facility above. LPA met with Administrator, Rebecca Michel and explained the purpose of the visit. LPA De Leon reviewed an incident report sent to Community Care Licensing (CCL) by the facility above. The incident report dated 07/26/2023 was regarding Resident 1 (R1) reporting at 8:00 pm R1 had a large new bump on left ankle, Staff 1 (S1) called Administrator and sent a picture. Hospice was contacted and facility was instructed to ice and elevate, and Hospice would be out in the morning to check on R1. At 12:30 am S1 noticed the bump had tripled in size sent another picture and called Administrator. Hospice was contacted again, and Hospice staff left VM with the Hospice on call doctor. The Hospice Nurse arrived at the facility at 2:05 am checked on R1’s leg and attempted to call the Hospice on-call doctor again leaving another message. Hospice Nurse administered medications to R1 for R1’s discomfort. S1 checked on R1 again at 3:30 am and 5:00 am noting R1 was sleeping. Hospice Nurse called the facility at 5:00 am stating the Hospice on-call doctor directed R1 to be taken by ambulance to the hospital. Administrator arrived at the facility at 6:00 am and at 6:15 am the bump on R1’s leg had opened, R1’s leg was wrapped several times to stop the bleeding. Paramedics arrived at 6:45 am and R1 was taken to French Hospital ER and was later discharged back to the facility around 11:00 am. LPA De Leon requested copies of R1’s Hospice Care Plan, R1’s hospital discharge paperwork and the photos that had been taken of R1’s leg/ankle. LPA De Leon received all the documents requested and reviewed all documentation sent. Continued 809-C The Hospice care plan dated 07/19/2023 for R1 does not mention a bump or a wound in the care plan. The Hospice nurse visit notes dated 07/26/2023 at 2:05 am stated R1 assessed for LE Wound, fluid filled blister, wound 26 cm (10 inch) X 12 cm (5 in), tender, medications issued for comfort, R1 able to answer simple questions, LE elevated on pillow, calls out in pain, collaborated with facility staff, wound left OTA at this time, wound supply dressing left in case blister opened, planned for further follow-up, attempted to reach Hospice on call doctor, VM left, supervisor on call made aware of situation and at 2:30 am wound outlined for reference. The Hospice Chart/Clinical Notes reporting period 07/26/2023 through 07/28/2023 stated RN assessed wound, LLE elevated on pillow, Instruction not to apply heavy blankets or ice packs to site, site left OTA at this time, dressing for wound left in case wound spontaneously opened, R1 cooperative with care but randomly called out, RN Administered medications for optimal comfort, Follow up scheduled for later this am with collaboration required with MD to determine POC, site with extreme edema and fluid that may need lancing, VMx2 left with Hospice Doctor and supervisor informed. Direct call received from Hospice on call doctor who is wanting R1 transported right away to ED to have wound evaluated and drained with option for pain control measures prior to care. French Hospital Discharge instructions were reviewed R1 had a visit date of 07/26/2023 with reason for visit being skin lesion bleed with a discharge diagnosis of a Hematoma. The Hospice care plan was updated as of 08/01/2023 for R1 and now mentions Wound/Skin in the care plan. Based on the record reviewed this was a new wound for R1 and was not part of R1’s Hospice Care Plan prior to 08/01/2023 therefore the facility should have provided timely medical attention for R1. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Aug 16, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 17, 2023

...residents regularly observed for changes in physical,... and that appropriate assistance is provided...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician...This requirement was not met as evidenced by: Based on record review and photographs the licensee did not comply with the regulation above R1 sustained a bump/wound called hospice instead of seeking timely medical attention for R1 which poses an immediate health, safety, and personal rights risks to resident in care.the state’s words, verbatim · CDSS document, Aug 16, 2023

Plan of correction: Administrator agreed to reevaluate facilities policy and procedures for timely medical attention, when to call 911, when to call hospice then train staff on all policies and procedures as well as regulations 87465 and 87469, provide an up-to-date LIC 500, with staff training records and all staff signatures to CCL. This page has been amended and regulation changed to 87466

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:30 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Rebecca Michel and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan, Emergency Disaster Plan. The facility has a sign in and out clipboard for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environment Safety: The facility has 14 bedroom and 4 bathroom for resident use currently occupying 15 residents and employs 18 staff. 1 restroom is designated for staff and visitors. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. All pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room. The laundry room has a working washer and dryer. The facility has sufficient space inside and outside for activities and visiting. The facility has a courtyard for resident use with an umbrella for shade and self closing, self latching locked gate with coded entry or exit and delayed egress.. The facility has telephone and internet service for resident use. The facility has 5 doors with delayed egress. The facility has three siting areas through out the facility for resident use. Continued 809-C Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/22/2023. The facility is approved for a capacity of 15 Non- Ambulatory of which all may be bedridden and a Hospice waiver for 8 residents. The facility is in compliance with these requirements. Staffing: The facility employes 18 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. One staff did not have health screening on file. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Personnel Records & Training: Staff training records were reviewed on 5 randomly chosen staff and those staff had 20 plus hours of training for 2023 meeting all required training topics. Administrator Certificate expires on 07/18/2024. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster is posted in the entryway of the facility and LTCO poster was posted in the common area. The current license along with CCL reports and PIN's were posted in the front office area. Visitation policy is posted at entry. Internet is provided to residents with confidentiality and privacy. Continued 809-C Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. The kitchen has two closing gates to keep dementia residents safe. Incidental Medical Services: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA observed medications where start dates were written on the labels and informed Administrator the facility can not write on the label and can use stickers on the top or bottom of the bottles. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drill and records were reviewed for both quarters of the 2023 year. The fire extinguishers were charged and last inspected on 07/05/2023. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked and in accessible to residents in care. The facility does have delayed egress. The facility does not currently have residents with oxygen. The facility has 3 hospice residents in care. Hospice care plans are kept on file and up to date. The facility does not currently have any residents on Home Health services. LPA conducted interviews with 3 Staff and 3 Residents. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Jul 28, 2023

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.

Allegation investigated: Staff did not seek timely medical care for resident.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA De Leon met with Co-Administratror Rebecca Michel and explained the purpose for the visit. On 8/26/2022, the Department received a complaint for this facility. It was alleged that Resident #1 (R1) sustained an unwitnessed fall that resulted in a fracture and staff failed to seek timely medical care for R1 after R1 was found on the dining room floor. The complaint was referred to Community Care Licensing Investigations Branch (IB) to obtain R1’s medical records and to confirm that dates of the fall and when medical attention was received. Continued 9099-C Substantiated On 08/29/2022, between 2:27pm and 3:45pm, Licensing Program Analyst (LPA) Rachael De Leon conducted a 10-day complaint visit to the facility. LPA De Leon met with Rebecca Michel, Co- Administrator and explained the purpose of the visit. The LPA requested documents pertinent to the investigation and took photos of the dining room area. The LPA determined further investigation was needed and would return on a later date to issue the final findings. LPA De Leon conducted interviews on 08/29/2022, from 11:23am to 2:30pm, with the Co-Administrator and R1’s resident representative. In addition, the IB Special Investigator Assistant (SIA) obtained and reviewed copies of French Hospital Medical Center medical records for R1. The facility file documents related to R1 were also reviewed. A review of the Special Incident Report (SIR) and the Co-Administrator’s written timeline of the incident revealed R1 was ambulatory without assistance and enjoyed walking freely around the facility. On 07/02/2022 after dinner, R1 continued to stay seated in the chair at the dining room table and dozed off. R1 fell out of the chair. Staff did not see R1 fall but saw R1 on the floor. Staff attempted to help R1 up and discovered R1 was in pain and not able to stand. Between 7:00 and 7:30pm, staff phoned the Co-Administrator, who was unavailable to come to the facility, but was able to FaceTime with the staff and observe R1 who appeared alert, eyes open and normal self. At approximately 7:45pm, the Co-Administrator phoned R1’s resident representative, who arrived at the facility shortly after and assisted the staff to get R1 off the floor, into the recliner to change, and assisted to bed. R1 was crying out in pain. At 9:00pm, R1’s representative texted the Co-Administrator to inform them that R1 was in bed sleeping and that R1’s left thigh area was swollen. The decision was made to wait until the morning to call 911 to see if R1’s condition was not improved or worsened. On 07/03/2022, at 7:30am, the Co-Administrator and R1’s resident representative observed R1’s hip area was very swollen. 911 was called and paramedics took R1 to French Hospital Medical Center. The complaint was referred to Community Care Licensing Investigations Branch (IB) to obtain R1’s medical records and to confirm that dates of the fall and when medical attention was received. On 08/29/2022, between 2:27pm and 3:45pm, Licensing Program Analyst (LPA) Rachael De Leon conducted a 10-day complaint visit to the facility. LPA De Leon met with Rebecca Michel, Co- Administrator and explained the purpose of the visit. The LPA requested documents pertinent to the investigation and took photos of the dining room area. The LPA determined further investigation was needed and would return on a later date to issue the final findings. LPA De Leon conducted interviews on 08/29/2022, from 11:23am to 2:30pm, with the Co-Administrator and R1’s resident representative. In addition, the IB Special Investigator Assistant (SIA) obtained and reviewed copies of French Hospital Medical Center medical records for R1. The facility file documents related to R1 were also reviewed. On the allegation: Due to neglect, resident sustained a fracture while in care. A review of the Special Incident Report (SIR) and the Co-Administrator’s written timeline of the incident revealed R1 was ambulatory without assistance and enjoyed walking freely around the facility. On 07/02/2022 after dinner, R1 continued to stay seated in the chair at the dining room table and dozed off. R1 fell out of the chair. Staff did not see R1 fall but saw R1 on the floor. Staff attempted to help R1 up and discovered R1 was in pain and not able to stand. Between 7:00 and 7:30pm, staff phoned the Co-Administrator, who was unavailable to come to the facility, but was able to FaceTime with the staff and observe R1 who appeared alert, eyes open and normal self. At approximately 7:45pm, the Co-Administrator phoned R1’s resident representative, who arrived at the facility shortly after and assisted the staff to get R1 off the floor, into the recliner to change, and assisted to bed. R1 was crying out in pain. At 9:00pm, R1’s representative texted the Co-Administrator to inform them that R1 was in bed sleeping and that R1’s left thigh area was swollen. The decision was made to wait until the morning to call 911 to see if R1’s condition was not improved or worsened. On 07/03/2022, at 7:30am, the Co-Administrator and R1’s resident representative observed R1’s hip area was very swollen. 911 was called and paramedics took R1 to French Hospital Medical Center. A review of R1’s hospital medical records, revealed R1 was taken to the hospital by ambulance and admitted to French Hospital Medical Center on 07/03/2022 and diagnosed with a Left Intertrochanteric Hip Fracture. The records state R1 had a mechanical fall the day before where they fell backwards. Staff observed R1 seated at the dining table after dinner, R1 dozed off, and then sustained an unwitnessed fall resulting in the fracture. Based on the information obtained, the allegation “Due to neglect, resident sustained a fracture while in care” is deemed Unsubstantiated at this time. On the allegation: Staff did not report resident's fall to Community Care Licensing. The LPA reviewed a copy of the Special Incident Report (SIR) for R1’s fall on 07/02/2022 which resulted in a fractured left hip. The SIR is signed and dated 07/07/2022 and was faxed to CCL on the same date. The SIR lists an incorrect date the fall occurred as 07/03/2022. During today’s visit, the Administrator was advised to submit a corrected SIR with the correct date occurred as 07/02/2022. Based on the information obtained, the allegation “Staff did not report resident's fall to Community Care Licensing” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued. A review of R1’s hospital medical records, revealed R1 was taken to the hospital by ambulance and admitted to French Hospital Medical Center on 07/03/2022 and diagnosed with a Left Intertrochanteric Hip Fracture. The nursing assessment note at 9:18am states patient fell last night at memory care facility. The history of present illness notation explains R1 was “brought in by ambulance from their long-term care facility after a fall yesterday.” It goes on to state that R1 had a mechanical fall the day before where they fell backwards. R1’s resident representative was called and immediately went to visit R1. “R1 seemed to be OK, so they put R1 back in bed.” R1 did complain of some left hip pain from what they could tell and there was some swelling, but they decided to wait it out overnight as R1 appeared comfortable once in bed. The next morning R1 has continued to complain of pain and is unable to bear any weight. Ambulance was then contacted. The facility “Fall Prevention Practice at Garden House” was reviewed and indicated to call 911 when there is: profuse bleeding; blow to head; resident can verbalize they are in pain; can’t walk. After R1 fell on 07/02/2022, R1 verbalized they were in pain and could not stand up by self. R1’s immediate complaint of pain, inability to stand up by self and visible swollen thigh area on 07/02/2022 should have prompted the facility to seek timely medical attention which they did not. 911 was not called until the next morning on 07/03/2022. R1 was admitted to the hospital and diagnosed with a left hip fracture. Based on the information obtained, the allegation “Staff did not seek timely medical care for resident” is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D) Exit interview conducted, deficiency cited, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Mar 23, 2023 · control 29-AS-20220826083247

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 24, 2023

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above. Staff did not obtain timely medical attention for R1 when R1 was discovered on the floor, complained of pain, unable to stand on own and had a swollen thigh which was later diagnosed as a fractured left hip, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 23, 2023

Plan of correction: Licensee will submit plan how you will ensure residents receive timely medical care. Submit to CCL by 03/24/2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 07/27/2022 at 11:30 AM. LPA met with back up to Administrator Rebecca Michel and explained the purpose of the visit. LPA took a physical plant tour of the facility with staff. The facility has submitted a mitigation plan to the department and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff, residents and visitors. All documentation is kept in a binders. The entry station has hand sanitizer along with a thermometer. The facility has a living room to accommodate activities, a dining room for dining, all areas are spaced to accommodate as much space as possible for social distancing. The facility has a large patio with shade for resident use. All equipment and PPE supplies are kept in the staff office. Medications are kept in a locked medication cart of the dining area. The staff screen residents for symptoms and temperature 1x's a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or has a temperature. Signs are posted on the front door, entry area and walls in common areas regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Continued 809-C Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Back up to Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 13 resident bedrooms and 4 resident bathrooms and they are disinfected after use. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. Facility Back up to Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Back up to Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities should be modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked cabinets in the staff office. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificates are valid. No deficiencies observed during the visit and all infection control protocols are implemented and are being followed. Exit interview completed and copy of report emailed to Administrator/Licensee.the state’s words, verbatim · CDSS document, Jul 27, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Rachael De Leon conducted an announced pre-licensing visit. LPA met with Zolton Soo, Administrator and explained the purpose of the visit. Applicant took LPA on a virtual plant tour of the inside and outside of the facility and the following is noted: Medications: There is a locked medication cart off of the dining room area. A small locked refrigerator is available for any refrigerated medications in the staff office area. Physical Plant: The facility is 14 bedroom with 13 single bedrooms and 1 shared bedroom, 4 shared resident bathrooms and 1 staff/visitor restroom, kitchen, dining room, living room, and locked laundry room. The facility has delayed egress on all exiting doors and the resident backyard patio has a secured fence with key coded gate for entry/exit. Facility is clean, sanitary and in good repair. Indoor and outdoor passageways, open porches, and other areas of potential hazard are free of obstructions. The facility does not have any pools or bodies of water. The facility does not store any firearms or ammunition. Any dangerous products/tools will be stored in locked cabinets and cupboards. All windows screens are clean and in good repair. Facility temperature is between 68-85 degrees. Facility does have areas with secured hand railings. The facility has smoke and carbon monoxide detectors. Bedrooms: The facility has 14 resident bedrooms and 1 is for double occupancy. Bedroom have beds for each resident with mattress, mattress pads, bed springs and pillows which are clean and in good repair. Mattresses and pillows are flame-retardant. The rooms have dressers and plenty of closet space for residents. The rooms are furnished with chairs and proper lighting /or lamps in each room for residents. Continued 809-C Bathrooms: The facility has 5 bathrooms, 1 for staff/visitors and 4 for residents use, all bathrooms have toilets and sinks. 2 bathrooms have showers. Bathrooms are located near resident rooms. There are night-lights in the hallways outside non-private bathrooms. Supplies: The facility has a sufficient supply of resident personal hygiene supplies, clean linens, towels and wash clothes. The supply of linens is sufficient for changing weekly or more if needed. Food Service: Dining room is near kitchen, Refrigerator and freezer are clean and large enough for the storage of at least two days of perishable food. Freezer is 0 degrees Fahrenheit and refrigerator was at 40 degrees which meets regulation requirements. A seven day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. Records: The facility has confidential storage for personnel and resident records, they will be kept on shelves in locked office areas. Administration: The facility has emergency plan and phone numbers posted, Residents rights, Facility visiting policy, Licensing Complaint Poster is posted in a prominent place at the facility. The facility has space for resident council meetings and resident council postings if needed. Activities: the facility has an activity calendar posted. There is an outdoor space with a shaded areas and furnished for outdoor use. There is at least one common room available for residents visitors. There are activity supplies, Art and crafts and games with a variety of reading material available. Miscellaneous: The facility has a current first aid manual with a first aid kit and all required supplies are present. There is working equipment for laundry. There is space for clean linen storage and separate space for soiled linen. The facility has an operating telephone available for residents use. Emergency lighting and supplies to include flashlights with batteries, emergency food supply and water is available for emergency use. Exit interview conducted, copy of report emailed to Applicant.the state’s words, verbatim · CDSS document, Jul 13, 2021