Gold Quartz Inn Retirement Home

Allegation investigated: Facility did not provide responsible party with former resident's records.

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA met with Administrator Loreen Hickman, and explained the purpose of the visit. LPA Valerio conducted the investigation, which consisted of interviews and record reviews. The Department has determined the following as it relates to the above aforementioned allegation. According to facility records, Resident 1 (R1) was admitted to the facility in late months of year 2022. R1 was involved in an accident in April of 2023. For reference, please see case management visit dated 05/04/23. On 07/22/23, R1 passed away at the facility. According to Records Review, R1's had a District Power of Attorney (POA) on file. On 08/11/2023, POA/Responsible Party for R1 requested records from Gold Quartz Inn Retirement Home. Continues on LIC 9099 - C... Substantiated Continued from LIC 9099 POA/RP requested a full and complete copy of R1's resident and business office files. On 08/14/23, Executive Managing Director, Ronald Regan, responded to R1's POA/RP. Ronald's response included the following: "The reference request for designated records from GQI, which is not a health care provider.... Therefore, your request for blanket resident information is denied since the GQI has no clear legal requirement for RCFE's to release records of a deceased resident. Cal.Code Regs Tit.22 § 87868 states that the admission agreement between the resident and the facility is automatically terminated by the resident's death, and that no liability or debt accrues after that date. This regulation could be interpreted to mean that [R1] does not have authority to seek copies of documents after the resident's death, as the agreement between the resident and the facility has ended. Based upon the foregoing, GQI may elect to not provide records. However, in an effort to settle the matter, GQI will provide resident payment records and relevant resident care file documents. A designed list of records will be provided on upon your agreement. The list of documents will include the number of pages for the response which will require a payment of $0.25/page of copies that can be emailed to your attention." LPA Valerio interviewed staff on 08/23/23. According to an interview with Administrator Loreen, Administrator Loreen stated that if anyone were to request records from staff, the staff will inform Loreen and she would take care of the request. Administrator Loreen stated if she is not available to preform the task, Fleta Herndon, may be available. According to an interview with Licensee Ronald Regan, Licensee Ronald is aware that R1 requested documents; however, he wants the POA/RP to request the documents in the right way. Licensee stated he would gladly send the documents if properly requested. According to an interview with the POA/RP, they have not received requested documents as of 09/25/2023. According to Health and Safety Code Section 1569.269, A resident of a RCFE has the right "To confidential treatment of their records and personal information and to approve their release, except as authorized by law." Per Title 22 regulations, 87506, "the licensee...shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative and Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. Per California Code of Regulations (CCR) Title 22, deficiencies are being cited on the attached LIC 809 -D. Failure to correct deficiencies may result in civil penalties. Appeal Rights Provided. An exit interview was held, a copy of the report was provided to Administrator Loreen Hickman.the state’s words, verbatim · CDSS document, Sep 26, 2023 · control 27-AS-20230816155055

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Oct 10, 2023

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on records review and interviews, R1's POA/RP records request has not been completed, therefore, the licensee and administrator did not conform to applicable laws, rules, and regulations. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2023

Plan of correction: The Licensee shall provide LPA Valerio a written statement acknowledging review of Health and Safety Code and Title 22 regulations and the facilities plan to ensure the POA/RP receives all documents requested by POC due date.

Allegation investigated: Staff did not secure resident's wheelchair appropriately in vehicle resulting in the resident tipping over sustaining injuries during a vehicle collision

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a 10 Day Visit, complaint investigation, and deliver complaint findings. LPA met with Administrator Loreen Hickman, explained the purpose of the visit. On 05/04/23, LPA Valerio and Licensing Program Manager (LPM) Richardson conducted a case management visit at the facility due to receiving notification of an incident that occured on 04/27/23. During the visit, LPA obtained documentation, interviewed staff, and observed staff preforming their procedures on how to secure a wheelchair in the van. After review of files and staff interviews, the facility was cited California Code of Regulations (CCR), Title 22, Section 87707(a)(2) for not ensuring all staff were properly trained on Van Procedures and Transportation. Continues on LIC 9099 - C Substantiated ...Continued from LIC 9099 According to the incident report submitted to the Regional Office, on 04/27/23 at 11:15 AM, Resident 1 (R1) was being transported to an appointment with Staff 1 (S1) and Staff 2 (S2). S1 was driving the facility van while S2 was sitting in the back of the van behind R1. S1 made a turn going 5 miles per hour. While turning, R1 fell while still in their wheelchair, landing on the floor and on their right side of their body. S2 assisted by elevating R1's head while on the vehicle floor. S2 performed verbal checks and assisted R1 back into the wheel chair after the fall and secured R1 to continue transportation to R1 appointment. R1 was observed to have a skin tear. S2 performed first aid. R1 was on the way to the doctor's office. R1's responsible party and primary care provider was notified. The doctor's office re-bandaged R1's injury and R1 will be provided home health follow up care. On 09/25/23, LPA reviewed a Traffic Crash Report from the Department of California Highway Patrol. According to the summary/case report, Staff 1 was driving the facility van, southbound on SR-49 at the intersection with SR-88 stopped at the stop limit line. As the traffic signal turning green, Staff 1 began to make the left turn and accelerated into the intersection at the stated speed of approximately 10-15 miles per house. At that speed, the wheelchair began to overturn to the right with [R1] still in the chair. Due to S1's unsafe turning movement, [R1] wheelchair fully overturned to the right allowing both [R1] and the wheelchair to fall, both striking the floor of the vehicle. Following the crash, [S1] and [S2] assisted [R1] back to an upright position, provided minor first aid, and continued to their original destination. According to an interview with the administrator, Administrator Loreen confirmed that S1 and S2 did not report the incident to CHP as they were already heading to R1's doctor appointment. Facility records confirm that S1 was not the individual to secure the wheelchair. S2 and S3 assisted R1 in the van. S1 and S2 did not double check to make sure the wheelchair was locked into a secure position. LPA reviewed pictures submitted by an outside agency of R1. Pictured is only the elbow to the middle forearm. The entire elbow and forearm region had evidence of bruising. This is evident by black, red, and purple colored skin. There is a skin tear roughly about 1 and 1/2 inch in diameter. Where there is a skin tear, it is bright red and black blood clots. Continues on LIC 9099 - C, Page 3... ...Continued from LIC 9099 - C Another picture was provided to the RO on 09/20/23. The picture shows Resident 1 drinking a drink while sitting in a chair. The resident has bruises on the face located under the eye, in the middle of the cheek, and below the ear. The resident also has a large bruise starting from proximal area of the forearm to the distal area of the forearm. The resident is show to have a large bandage wrapped around her forearm. Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached LIC 9099 - D. Failure to correct deficiencies may result in civil penalties. Appeal Rights Provided. An exit interview was held, and a copy of the report was provided. Licensee was informed that an immediate civil penalty of $500 is issued in addition to citation due to injury related to violation of Section 1569.312(e). At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f). This report was amended to reflect the assessment of the civil penalty and possible civil penalty might be assessed based on Health and Safety Code § 1569.49(f).the state’s words, verbatim · CDSS document, Sep 26, 2023 · control 27-AS-20230920142634

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 10, 2023

87468.2 Additional Personal Rights of Residents (a)In addition to.. Section 87468.1,.. residents...shall have all of the following: (4)To care, supervision, and services that meet their individual needs ...delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidenced by: Based on records review and interviews, the licensee neglected to ensure R1's needs were met by staff, which resulted in R1 sustaining injuries. This poses a potential health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2023

Plan of correction: Licensee stated they conducted and completed training on Transportation Procedures during May and June of 2023. Licensee stated facility staff will continue refresher training every 6 month/as needed. By the POC due date, Licensee will submit a statement of their training plan/procedures.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived to the facility unannounced to follow up on an incident that occurred on 04/27/2023. LPA met with facility staff and Senior Executive Director Fleta Herndon, and explained the purpose of the visit. The incident report stated that on 04/27/23 at 11:15 AM, Resident 1 (R1) was being transported to an appointment with Staff 1 (S1) and Staff 2 (S2). S1 was driving the facility van while S2 was sitting in the back of the van behind R1. S1 made a turn going 5 miles per hour. While turning, R1 fell while still in their wheelchair, landing on the the floor and on their right side of their body. S2 assisted by elevating R1's head while on the vehicle floor. S2 performed verbal checks and assisted R1 back into the wheel chair after the fall and secured R1 to continue transportation to R1 appointment. R1 was observed to have a skin tear. S2 performed first aid. R1 was on the way to the doctor's office. R1's responsible party and primary care provider was notified. The doctor's office re-bandaged R1's injury and R1 will be provided home health follow up care. The facility reported the incident to LPA on 05/01/23 and sent in an incident report on 05/03/23. During a phone conversation with Administrator Loreen, Administrator stated they are conducting an internal investigation and will send copies of the staff statements to LPA. Per Administrator, the van was assessed by the maintenance worker. The van is in working condition and was used to transport residents. LPA requested facility documentation related to the incident. Facility staff provided doctor visit documentation. LPA requested staff statements. Licensee Ron informed Fleta that he will not release the statements to LPA based on the guidance provided by their attorneys. The attorneys were to review the statements and give approval to release the statements. LPA provided Technical Assistance to Fleta to inform and remind Licensee Ron of Title 22 87755 (c), which states, "The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b)." Continues from LIC 809... At 11:12 AM, LPA Valerio and LPM Richardson received an email composed of the statements from staff that were present before and after the incident. Staff statements were reviewed. On 05/02/23, the regional office was sent a picture of R1's injuries. The picture was reviewed and details were documented. Based on review, the picture indicates an approximate 1 and 1/2 inch skin tear with evidence of ecchymosis "bruising" on the entirety of the upper forearm. According to staff interviews, staff have not seen the injury recently due to home health taking care of the skin tear. Staff stated the resident has attended follow-up appointments and will continue to receive follow up care from home health. LPA requested personnel files and staff training records. LPA observed 3 staff files. LPA and LPM did not observe staff in-service training pertaining to how to properly secure wheelchairs into the facility van or topics related to operating the facility van. During facility records review, the licensee did not ensure 3 out 3 staff files reviewed had up-to-date training. S1 received 13 hours of training in 2022 and 0.75 hours of training in 2023. S2 had 0 hours of training received for 2022 and 2023. S3 received 14 hours of training in 2022 and 0 hours of training in 2023. This poses a potential health and safety risk to residents in care. Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies were observed and citations can be found on LIC 809 - D. Failure to correct the deficiencies may result in civil penalties. An exit interview was held with Senior Executive Director Fleta Herndon, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 4, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87707(a)(2) · Plan of correction due date: May 5, 2023

87707 Training Requirements...(a) Licensees.. shall...meet the following training requirements: (2) Direct care staff shall complete at least eight hours of in-service training...within 12 months of working in the facility and in each succeeding 12-month period... This requirement was not met as evidenced by: Based on observations, records review, and interviews, the licensee did not ensure staff received updated training on how to properly secured residents with a wheelchair in the facility van. This resulted in a resident getting injured during transport, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2023

Plan of correction: Licensee stated all facility staff will receive in-service training. Licensee to send LPA a copy of in-service training with staff signatures acknowledging understanding of "Procedures to Transport a Wheelchair Resident in Gold Quartz Van"

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c) · Plan of correction due date: Jun 1, 2023

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 Based on records review and interviews, the licensee did not ensure 3 out of 3 staff files reviews received required annual training. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2023

Plan of correction: Licensee stated the administrator will go through all staff files to determine which files are out of date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual visit. LPA met with facility staff, and explained the purpose of the visit. Upon arrival, LPA noticed construction work in the front entrance of the building. LPA took pictures for reference. The facility is a two story building. In order to enter the facility, a person needs to walk across a bridge walkway. According to staff, the facility started working on the new walkway a few weeks ago. The new and temporary ramp was installed this week. LPA was not made aware of the repairs. LPA requested the building permit. Licensee Ron R. came to the facility around noon and gave LPA the building permits and construction blue print. A technical advisory was given regarding notifying CCL of any repairs or modification done to the facility. Title 87305 Alterations to Existing Building or New Facilities was discussed with Licensee and Executive Director (ED) Fleta Herndon. LPA toured the facility to ensure compliance of title 22 regulations. LPA toured the facility with facility staff. Hot water was measured at 108.7*F in two bathrooms. The facility common areas, including the activity room, dinning hall, day room, and hallways, were observed to be organized and free from debris. The elevator inspection is up to date. Fire extinguishers are up to date and fully charged. After the tour, LPA was met by Licensee Ron and ED Fleta. LPA discussed findings of the tour with ED and Licensee. The ED designated the lead staff on shift to sign off on the report. During the tour, LPA observed room 113. This is a empty resident room on the bottom floor. LPA observed construction items, bed frames, unused mattresses, and other tool items in the room. LPA heard voices in the bathroom. According to interviews, this room is utilized by staff to give showers to residents due to the walk in shower. Licensee was informed of the situation and had hazardous items removed from the room into another vacant room. Continues on LIC 809 - C... Page 1 of 3 Continued from LIC 809 LPA was at the facility for majority of the day. During this time, there were no planned activities for the residents. According to staff, today is the activities director day off. LPA observed a staff member telling a resident there were no activities for the day. LPA requested the following copies: LIC 500, LIC 308, Liability Insurance, LIC 90999 - Current Facility sketch with current emergency exits, LIC 610E Current Disaster Plan Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies are being cited. Appeal rights were provided. An exit interview was held with staff, and a copy of the report provided. LPA to send copies of the report to ED Fleta Herndon and Assistant Administrator Loreen Hickman. .the state’s words, verbatim · CDSS document, Jan 26, 2023

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility is violating resident's personal rights Facility did not complete an updated needs and service plan Facility is sharing information with unauthorized representative Facility is not meeting food service requirements

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation findings. LPA met with facility lead staff, and explained the purpose of the visit. The department has determined the following as it relates to the allegations: Facility is violating resident's personal rights, Facility did not complete an updated needs and service plan, Facility is sharing information with unauthorized representative, Facility is not meeting food service requirements According to interviews with staff, staff have never observed or admitted to violating any resident's personal rights. According to staff, they continue to provide care and ensure their needs are met as best as they can. One staff stated, "If someone were to ask for help, I would help them. If I was getting paid or not, I am here for the residents." According to resident interviews, the staff are nice, treat the resident's good, and the facility is a good place. According to facility observations, LPA did not observe any personal rights violation on 10/04/22, 10/20/22, 11/18/22, or 12/28/22. Unsubstantiated LPA reviewed facility records for resident's on hospice. Resident 1 had an assessment completed on 10/11/2017. According to records, an updated assessment was done in 2021. For 2022, a care plan was re-established on 03/03/22 and 04/27/22. Resident 1 also had an updated LIC 602 with a date of 03/10/2022. According to staff interviews, care plan assessments are completed in their QUICK MAR system. According to an interview with an outside agency, the facility listed a patient (resident 2) on hospice with dementia; however, the resident does not have dementia. According to a previous staff, R2 has always been observed to be coherent and should not have been diagnosed with dementia. According to records review, the facility had a care plan updated on 03/24/22 and 08/02/22. According to an interview with the assistant administrator, a nurse diagnosis R2 with dementia during a visit. The assistant administrator asked for proof regarding the diagnosis to ensure the care plan is accurate. LPA Valerio interviewed residents, staff, and an outside agency regarding staff sharing resident information with unauthorized representatives. According to two interviews, it was heard that staff are taking videos of residents on their cell phone and then laughing about it. One staff stated, "I know we have used snap chat filters to have it for fun during activities. We always ask for consent. We post them in our activities room and/or for Facebook. We have all residents sign a consent form." LPA reviewed resident records and confirmed that each resident has a signed consent for photographs/videos to be taken for the purpose of activities, newsletters, and family. According to staff, a sign was created because staff were discussing who left to the hospital with another resident. The sign posted stated, "We are not to share any personal information on the resident, yourself or any other person in the community." According to an interview with R2, R2 stated there was an issue with R2's family member for about a week. R2 stated R2 is involved in treatment meetings and has appointed a new power of attorney. LPA interviewed staff regarding the facility's food service. Staff stated there is an ample amount of food, they try to make everything in house, they give options to resident's, they will offer seconds to resident, they have a dietitian make the menu, and they adjust the menu based on resident wants, supply, and diet. Other staff stated that depending on the cook staff, there might be a change in presentation for food. One cook staff only cooks frozen foods and another staff cooks home-made meals. Continues on LIC 9099- C... page 2 of 3 According to another staff, the staff will order food and lead management will adjust the order based on budget. There are times where the facility does not get everything that was initially ordered. According to a family member, the food smelled so good, they wanted to stay for dinner. Based on observations of meal times and the facility menu, the facility offers balanced and appetizing food items. According to an interview with a resident, resident stated, "they have a variety of food, such as ground beef, pulled pork, and chicken." Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, 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, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was given to facility lead staff. Page 3 of 3.the state’s words, verbatim · CDSS document, Dec 28, 2022 · control 27-AS-20220929140325

Allegation investigated: Facility is not providing residents transportation to medical appointments. Facility staff member did not assist resident with a brief change in a timely manner resulting in resident sitting in feces for an extended period of time. Facility staffing is not sufficient to meet the needs of the residents.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to investigate the above mentioned allegations on 11/17/22 at 12:30p. LPA met with Amber Warren, PM Supervisor and stated the purpose of the visit. LPA interviewed resident #1 (R1) - (R7) and Staff #1 (S1) - (S6). Regarding allegation, "Facility is not providing residents transportation to medical appointments." LPA toured the facility van with S3 and took pictures of the ramp inside and the step stool. LPA attempted to lift the ramp which was extremely heavy. LPA observed the stool to contain duck tape to hold the legs together. S3 is currently unable to lift the ramp to assist residents onto and off the van which in turn does not allow the residents to be transported. S3 is the only transportation driver for the facility van at this time. The ramp is not broken it is too heavy for S3 to lift due to medical reasons and possibly a second transport staff would be needed to lift the ramp to assist residents on and off the van for appointments. LPA obtained information that the facility is utlizing the van from next door which is not licensed by Community Care Licensing (CCL) to assist, however the lift on that van is broken. Substantiated LPA observed in the Plan of Operation submitted to Community Care Licensing (CCL) upon Licensure that the facility under Basic Services Provision or arrangement for transportation to local functions such as church or doctor appointments within a near by radius will be provided. And under Transportation Transportation is provided by several means...and residents special need in the facility van. Based on interviews, the preponderance of evidence standard has been met. Regarding allegation, "Facility staff member did not assist resident with a brief change in a timely manner resulting in resident sitting in feces for an extended period of time." LPA conducted interviews of (S1-S6) and (R1) which revealed that residents are not being changed timely for incontinence. This personal rights violation would be residents bedding not being changed with the incontinence care leaving brown spots on the bed and leaving the resident in urine and/or feces for an extended period of time. LPA observed in the Plan of Operation submitted to Community Care Licensing (CCL) upon Licensure that the facility under Basic Health Services facility will provide observation and assistance with personal needs and bedside care needs. Based on interviews, the preponderance of evidence standard has been met. Regarding allegation, "Facility staffing is not sufficient to meet the needs of the residents" LPA conducted interviews of (S1-S6) and (R1-R7) which revealed conflicting information. LPA obtained information that the facility is cross training/working staff. In addition, LPA received information that care staff are used to transport food to the independent apartments next door on a daily basis for all meals. There is at this time 26 residents and 1 caregiver to each floor with 1 Medication Technician. Specifically, on days when 1 staff does not work there is only 1 caregiver and MT 1 of which is used to deliver meals to the independent apartments next door during their shift which leaves an insufficient number of staff for the supervision of residents. Based on interviews the facility is in need of additional staffing. Based on interviews, the preponderance of evidence standard has been met. Based on interviews and observations, the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 17, 2022 · control 27-AS-20221109113829

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208(a)(8) · Plan of correction due date: Nov 18, 2022

Plan of Operation Transportation arrangements for persons served who do not have independent arrangements. This requirement is not met as evidenced by: Observation Staff is unable to utilize the ramp to assist residents onto and off the van while using a wheelchair Based on interviews, the licensee did not ensure van is properly equipped for the safety of staff and residents This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 17, 2022

Plan of correction: Licensee shall submit a plan on how to accommodate ambulatory and non ambulatory residents who need transportation for appointments as stated in Plan of Operation. Please fax to (916) 263-4744 by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(1-3) · Plan of correction due date: Nov 18, 2022

Managed Incontinence In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Interviews that staff is not assisting residents with incontinence timely Based on interviews, the licensee did not ensure staff is assisting residents with incontinence This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 17, 2022

Plan of correction: Licensee shall submit a plan on conducting an in-service for staff regarding caregiveing procedures and scheduled incontinence care for all residents. Please fax to (916) 263-4744 by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 18, 2022

Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Interviews staff is insufficient in numbers to provide care and supervision Based on interviews, the licensee did not ensure sufficient staffing who are used to asssist independent apartments next door This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 17, 2022

Plan of correction: Licensee shall submit a plan on how to accommodate their licensed RCFE and the independent apartments next door. Please fax to (916) 263-4744 by POC due date.

Allegation investigated: Facility did not ensure medication destruction record is maintained Facility did not provide supervision of residents narcotic medication

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA met with facility staff, and explained the purpose of the visit. The department has concluded the following as it relates to the above mentioned allegations. The individual designated to sign was medication technician lead, Brandee Smith. On 06/09/2022, the department received an incident report from the facility stating it was discovered on 06/05/2022 that narcotic medications (3 pills) were found to be missing from the facility. On the day the pills were discovered to be missing, 3 staff were called to confirm the medication count. According to interviews, staff stated that they do not know where the medications went or if anyone had taken the medications. Staff statement reveal that not all shifts completed a medication count for the narcotic medications. Another staff statement revealed that the facility pre-pours medication for the oncoming shift so staff are unable to attest to which medication was poured. Continues on LIC 9099 - C... Substantiated Continued from LIC 9099 On 07/07/2022, the department received an incident report from the facility stating it was discovered on 06/30/2022 that narcotic medication (entire bottle) were found to be missing from the facility. After an internal investigation, facility records reveal that narcotic medication sheet was deleted from the facility excel system. This document would be able to show the narcotic count for the pill bottle. The facility admitted that the medications and medication document were not found. Since the incident, the facility implemented a triple check system for narcotic medications and had medication staff undergo additional training through Relias. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Oct 20, 2022 · control 27-AS-20220720142919

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e) · Plan of correction due date: Nov 21, 2022

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.. This requirement was not met as evidenced by: Based on records review and interview, 1 resident medication records were missing from the facility,which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: Licensee stated a new system will be implemented by POC due date. The licensee will save back up files on a USB drives at the start of each month. Licensee to send proof of medication back up sheets to LPA via fax.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Nov 21, 2022

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...This requirement was not met as evidenced by: Based on record review and interviews, the facility did not ensure medication for resident 1 and resident 2 were kept safe and locked away, which caused the medications to come up missing. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: Licensee stated they have implemented a triple check system. Licensee to send copies of count sheet for October and November to LPA by POC due date.

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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility. Administrator confirmed staff and residents have not displayed any signs or symptoms of COVID-19 in the last 10 days. The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. There were no observed health or safety concerns. LPA conducted the infection control domain tool. LPA Valerio discussed the recent PINs and mandates with Administrator and staff. The facility has a plan to have all eligible staff boosted by the February 1st, 2022 deadline. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. LPA observed the facility to have COVID-19 informational, hand washing signs, and sign in sheet posted at the front door and throughout the facility. The facility has a designated infection control lead. The facility is able to designated and dedicated a COVID-19 bedroom and bathroom if needed. LPA observed the temperature inside the facility was measured at 72*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 114.1*F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Fire extinguishers was up to date with last check on 11/26/2021. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Jan 10, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual inspection. LPA met with facility staff Loreen Hickman, stated the purpose of today’s visit, and was allowed entry after being screening for COVID-19 symptoms with temperature taken. Staff confirmed residents and staff have not had any signs or symptoms of COVID-19 in the last 10 day. The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA also conducted the infection control domain tool. The facility submitted a LIC 808 mitigation plan. LPA observed the facility to have a first aid kit, hand washing signage, and COVID - 19 informational signage posted at the front door and throughout the facility. The facility is able to designate and dedicated a Covid-19 bedroom and bathroom if needed. Common touch surfaces are cleaned after each use. LPA observed the temperature inside the facility was measured at 74*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 110.1 *F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility has food supplies: nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. The centrally stored medications area to be locked and inaccessible to clients. LPA Valerio observed a pull alarm system, fire extinguisher(s) with last check on 11/20/2020, smoke and carbon monoxide detectors, central heating and air in the facility. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given to Administrator Machellee Alllison.the state’s words, verbatim · CDSS document, Nov 10, 2021