Grandview Guest Home

Type of visit: Case Management - Annual Continuation

On 10/04/2023 at 1:45 PM, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Continuation Inspection and met with Coty Cabral, President. Five (5) residents and three (3) staff were present during this inspection. Administrator, LPM, and LPA tested the smoke detectors and carbon monoxide, interviewed two staff and two residents, reviewed five staff records, infection control, emergency disaster plan, and plan of operation. Common areas were clean and clear of hazards, doorways were free of obstructions. The hot water temperature properly measured at 108.3F. One fire extinguisher, last serviced February 10, 2023 was observed in the kitchen area. An exit interview was conducted and technical assistance was reviewed. A copy of this report was discussed and left with Coty Cabral, President.the state’s words, verbatim · CDSS document, Oct 4, 2023

The state marks this report as 5 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 10/032023 at 2:51 PM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Coty Cabral, President. Five (5) residents and three (3) staff were present during this inspection. Facility is licensed to serve six (6) non-ambulatory residents, one (1) may be bedridden. The facility also has an approved hospice waiver for three (3) residents. The Annual Licensing Fees are current. The home consists of 1 floor level with: 4 resident rooms (Room 2 is designated for bedridden), 2 restrooms, kitchen, dining room, living room, and garage. The President accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Common areas were clean and clear of hazards, doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. 5 resident records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. 2 resident medication and MAR were reviewed. During record review, LPA did not observe an infection control plan nor an indication whether the emergency and disaster plan was reviewed or updated. Technical assistance was provided. Due to time constraints a Case Management - Annual Continuation visit will be conducted. A copy of this report was provided to Coty Cabral, President.the state’s words, verbatim · CDSS document, Oct 3, 2023

Type of visit: Required - 1 Year

On 11/302022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA Montoya conducted a risk assessment with Licensee Coty Cabral who confirmed the facility is free of Covid-19 infection. LPA met with House Manager Alberto Simon and explained the purpose of today’s visit. The facility is licensed for age range 60 and over; approved for six (6) non-ambulatory, of which 1 may be bedridden; hospice waiver approved for three (3) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, two (2) bathrooms, one (1) living area, one (1) dining area, laundry area, kitchen, and covered outside patio. There is an attached garage used for storage only. LPA Montoya toured the facility with House Manager Alberto Simon. Licensee Cabral arrived later and joined the visit. During the tour, LPA did not observe bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The water temperature measured at 117.2 degrees Fahrenheit. A comfortable temperature was maintained in the facility. LPA observed the facility is appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Smoke detectors and carbon monoxide were operable. Report continued in LIC809C During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Licensee Coty Cabral.the state’s words, verbatim · CDSS document, Nov 30, 2022

Allegation investigated: Resident eloped from facility.

On 10/7/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a 10-day complaint visit at this facility. LPA Montoya called and conducted a risk assessment with Licensee Coty Cabral. The facility is free of Covid-19 infection. The facility is free of Covid-19. LPA met with Staff Floradima Suasa (S3), Staff Elizabeth Vergara (S4) and Staff Alberto Simon. LPA explained the purpose of the visit. The investigation consisted of the following: LPA Lourdes Montoya toured the facility with Staff Elizabeth Vergara (S4). LPA observed three (3) staff and six (6) residents during the visit. LPA interviewed S4. LPA made an unsuccessful attempt to interview a resident (R1) and four (4) potential witnesses (W1-W3). REPORT CONTINUED IN LIC 9099C Substantiated INVESTIGATIONS REVEALED: ALLEGATION: Resident eloped from facility. It is alleged Resident #1 (R1) eloped from facility. Reporting Party stated, "R1 presents with mild insight and awareness and recalls eloping from Grand View Guest House due to poor treatment”. Based on LPA’s review of R1’s admission agreement, R1 was admitted to the facility on 8/8/2022. Physician’s Report shows R1 is ambulatory and has dementia. It also stated that “R1 is not Able to Leave Facility Unassisted”. Based on interviews and record reviews conducted, Staff (S1-S3) admitted R1 left the facility on 9/8/2022 without staff knowledge and supervision. S1 revealed R1 was located by police officers inside Bank of America in Santa Monica. S1 stated R1 did not return to the facility. Based on LPA’s interviews and record reviews conducted, there is sufficient evidence to corroborate the above allegation. Based on LPA observations and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted and Appeal Rights was discussed with House Manager Albert Simon. A hard copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Oct 7, 2022 · control 11-AS-20220912165148

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Oct 8, 2022

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met as evidenced by: Based on interviews and record reviews conducted, Resident #1 eloped from the facility without supervision. This poses an immediate risk to health, safety and/or personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2022

Plan of correction: The licensee will submit a plan of correction outlying steps to take to ensure that Dementia residents do not elope from the facility in the future. POC will be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 10/8/2022.

Allegation investigated: Resident lost 5 lbs a day for not eating.

On 10/7/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent complaint visit at this facility. LPA Montoya called and conducted a risk assessment with Licensee Coty Cabral. The facility is free of Covid-19 infection. LPA met with Staff Floradima Suasa (S3), Staff Elizabeth Vergara (S4) and Staff Alberto Simon. LPA explained the purpose of the visit. The investigation consisted of the following: LPA Lourdes Montoya toured the facility with Staff Elizabeth Vergara (S4). LPA observed three (3) staff and six (6) residents during the visit. LPA interviewed S4. LPA made unsuccessful attempts to interview a resident (R1) and four (4) potential witnesses (W1-W4). REPORT CONTINUED IN LIC 9099C Unsubstantiated INVESTIGATIONS REVEALED: ALLEGATION: Resident lost 5 lbs a day for not eating. It is alleged Resident #1 (R1) lost five (5) lbs a day for not eating. Based on R1's admission agreement, R1 was admitted to the facility on 8/8/2022. R1’s Physician's Report dated 7/26/2022 shows R1 weighed 103 lbs. There is no available record showing R1's current weight during the incident (9/8/2022). Based on LPA's interview with Staff (S1-S4) and Residents (R2, R6 and R7), they have not observed any residents losing five (5) lbs a day. Staff (S1-S4) stated R1's body frame is petite and R1's eats low- carb diet. LPA attempted to contact potential witnesses (W1-W4) to obtain additional information but LPA was unable to reach them. Based on LPA’s interviews and record review, there is no sufficient evidence to corroborate the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is Unsubstantiated An exit interview was conducted with House Manager Albert Simon, and a hard copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2022 · control 11-AS-20220912165148

Allegation investigated: Staff ignores resident. Staff are making resident feel uncomfortable.

On 9/19/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a 10-day complaint visit at this facility. LPA Montoya called and conducted a risk assessment with Licensee Coty Cabral but Cabral's voicemail box was full. LPA proceeded to the front of the facility and knocked on the door. Coty Cabral opened the door and LPA conducted a risk assessment prior to entering the facility. Cabral confirmed the facility is free of Covid-19. The purpose of the visit was explained. The investigation consisted of the following: LPA Lourdes Montoya toured the facility with Licensee Coty Cabral. LPA attempted to interview the alleged victim (R1) but R1 was no longer residing in the facility during the visit. LPA was unsuccessful in her attempts to interview R1 by telephone. LPA observed three (3) staff and six (6) residents during the visit. LPA Montoya interviewed all three (3) staff (S1-S3) and three residents (R2, R6 and R7). LPA was unable to interview two residents (R3 & R5) because of their medical conditions and one resident (R4) was sleeping. LPA requested copies of Resident #1’s service records (Identifcation and REPORT CONTINUED IN LIC 9099C Unsubstantiated Emergency Information, Admission Agreement, Physician’s Report, Appraisal/Needs and Services Plan) and the facility’s dementia plan, dementia staff training, staff roster, resident roster, and other pertinent records. INVESTIGATIONS REVEALED: Allegation: Staff ignores resident. It is alleged that staff ignores resident when resident asks for assistance. Based on LPA’s interview with Staff (S1-S3) and Residents (R2, R6 and R7), they have not heard or observed any staff ignoring any resident asking for assistance. Based on LPA's observations and interviews conducted, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff are making resident feel uncomfortable. It is alleged that staff are making resident feel uncomfortable. Based on LPA’s interview with Staff (S1-S3) and Residents (R2, R6 and R7), they have not heard or observed any staff making any resident feel uncomfortable. R2 stated all staff are very good to her. R2, R6 and R7 stated they all like living in this home. Based on LPA's observations and interviews conducted, there is no sufficient evidence to corroborate the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated An exit interview was conducted with Licensee Coty Cabral, and a hard copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2022 · control 11-AS-20220912165148

Type of visit: Prelicensing

On 09/21/2021 around 10am Licensing Program Analysts (LPA) Jose Calderon conducted an announced face to face visit with Licensee Coty Cabral for purpose of a pre-licensing evaluation. The requested capacity is for 6 adult residents of which there is 1 ambulatory/ 5 non-ambulatory Adult Residents. Facility is a 4 bedroom, 2 bathrooms, one-story house. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a backyard with a covered patio for shade. The patio contained 1 small table and 3 chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Residents Bedrooms: All 3 Bedrooms are for ambulatory/non-ambulatory clients. Bedroom’s #1 and #2 and #3 has one bed each, one chair, one-night stand, one lamp. There are dressers within the closet for each resident. Bedrooms #1, #2 and #3 all comply with the requirement of 8 cubic feet of space. Bathroom: Have a working toilet, wash basins, and walk-in shower. Bathroom #1 shower is missing grab bars, but licensee states bathroom #1 is for ambulatory only residents. LPA observed adequate lighting in hallway leading to bathrooms. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hall closet. Emergency Phone Numbers, Exit Plan & Menu: The telephone system is a land line and operable. Emergency Disaster Plan and "See something, say something Let Us Know" were missing. Fire Extinguisher 1 mounted on the wall in hallway next to the front door. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet located in the kitchen area. Food supply is not adequate; no food was found in the kitchen refrigerator and 7 days of dry food was found in the kitchen pantry which consisted of dry pasta, canned foods. Smoke Detectors: 4 hard wired smoke detectors are battery and electric. operated & working. Carbon monoxide detector located and mounted in the hallway is operational. Appliances: Gas Stove, oven, microwave, washer, and dryer working. Refrigerator in the kitchen has a measured temperature of at least 41 degrees Fahrenheit for appropriate food storage. Freezer is at 19 degrees Fahrenheit. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. Toxins: Locked/stored in the storage room located in the kitchen. Water Temperature: Bathrooms water temperature tested in #1 at 105 F. and #2 106 F. degrees, kitchen sink temperature tested at 115 F degrees. Medications, First-Aid Kit & Book: Medication administration records storage area, and first aid kit has been inspected, which are stored in locked kitchen cabinet adjacent the refrigerator, available for staff use but inaccessible to clients. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the client's use. LPA did not observe any pet or bodies of water at the facility. LPA did not observe delayed egress, chain locks or dead bolts on exits. LPAs did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Pool/Jacuzzi & Pets: LPA did not observe any pet or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 09/14/2021 for 2 ambulatory/4 non-ambulatory clients with no special instructions. LPA did not observe delayed egress, chain locks or dead bolts on exits. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected: · Bedroom #1, missing a dresser · No food was found inside refrigerator · No 30-day supply of PPE’s were found If additional time is required to complete noted items to correct, then the applicant will request an extension prior to the due date. Component III: (09/21/2021) about how to operate the facility within substantial compliance was not reviewed by the licensee at this time. LPA Calderon emailed component 3 to licensee for her review During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be emailed to LPA Jose Calderon by 09/24/2021. If additional time is required to complete noted items to correct, then the applicant will request an extension. An exit interview was conducted, and a copy of this report has been furnished to the applicant by hand. Accordingly, LPA Jose Calderon will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Sep 21, 2021