Grey Manor

Allegation investigated: Licensee admitted resident without a medical assessment signed by a physician within one year. Licensee prohibited resident from having visits.

Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to deliver the findings of the allegations cited above. LPAs met with Assistant Administrator, Kassie Howell, and explained the purpose of the visit. During this investigation, the Department conducted interviews and file reviews. At this time, the allegations listed above has been detemined as unfounded, as the alleged incident occured at a different facility. UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis. LPAs will open a new complaint to the correct facility. Exit interview and acopy of the report and appeal rights provided. Unfoundedthe state’s words, verbatim · CDSS document, Oct 19, 2023 · control 59-AS-20230412145121

Allegation investigated: Residents are chemically restrained with medication Facility staff not fingerprint-cleared Staff are using drugs while on duty Facility staff are abusing residents

On 10/5/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to deliver the findings of the allegations cited above. LPAs met with Administrator, Karl Ramos, and explained the purpose of the visit. During this investigation, the Department conducted extensive interviews and file reviews. The results of the investigation are as follows. Please continue on LIC 9099-C... Unfounded Allegation: Residents are chemically restrained with medication. Based on interviews conducted with S1, S2 and Administrator, it revealed that residents are only administered medications that are physician ordered. Interviews and medication review revealed that five residents are prescribed Melatonin, four are scheduled medication and one is as needed medication. LPAs observed medications to be given as ordered and no errors for residents. Based on information obtained, LPAs finds the allegation to be UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis. Allegation: Facility staff not fingerprint- cleared. Based on file review, LPAs reviewed staff files for (3) staff, including photo ID, and observed that all staff are fingerprinted cleared and associated to the facility. LPAs confirmed via Guardian that S1, S2 and Administrator are fingerprint cleared. Based on information obtained, LPAs finds the allegation to be UNFOUNDED- means that the allegation is false, could not have happened, and/or is without a reasonable basis. Allegation: Staff are using drugs while on duty. Based on interviews with staff and residents, it revealed there are no concerns and/or suspicions of staff using drugs while on duty. Based on observation, LPAs conducted a tour of staff room and no deficiencies observed. Based on information obtained, LPAs finds the allegation to be UNFOUNDED- means that the allegation is false, could not have happened, and/or is without a reasonable basis. Allegation: Facility staff are abusing residents. Based on interviews with staff and residents in care, it revealed residents do not have any concerns with staff. LPA Yang observed residents watching television during time of inspection on 4/6/2023. Interview with R1 and R2, staff are nice and accommodating to residents in care. Based on information obtained, LPAs finds the allegation to be UNFOUNDED- means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Copy of report and appeal rights was provided to Administrator.the state’s words, verbatim · CDSS document, Oct 5, 2023 · control 59-AS-20230328163330

Type of visit: Required - 1 Year

On 10/5/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a Required 1- year annual inspection utilizing the care tool. LPAs met with caregiver, Kassie Howell, who contacted Administrator, Karl Ramos, who arrived to the facility shortly afterwards. LPAs and Caregiver conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: six private residents room, two bathroom, kitchen, backyard, storage area, and the common areas. LPAs observed three residents in the common area watching television and two residents in their private rooms. LPAs observed the facility to have 2+ days of perishable and 7+ days of nonperishable foods. LPAs observed the laundry door to be unlock. LPAs observed cleaning solutions to be stored in the laundry room. LPAs informed caregiver although facility is in the middle of laundry, door shall be locked at all times. LPAs conducted a file review of personnel and residents records. LPAs observed one staff file to be incomplete with the required documents. LPAs provided facility with a copy of California Code Regulation 87412 Personnel Records. LPAs additionally provided facility with a list of the required documents for staff files. LPAs completed the full care tool and deficiencies was observed. Please see LIC 809-D. Exit interview conducted and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Oct 5, 2023

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a post-licensing inspection utilizing the post-licensing inspection tool. LPA met with Assistant Administrator (Asst Admin), Noel Estillore, and explained the purpose of the visit. Today's census is 6 with (3) resident on hospice services. Facility is licensed for capacity of 6 and hospice waiver of 6. LPA and Asst Admin conducted a tour together to ensure the health and safety of residents in care. In areas toured included but not limited to the common areas, kitchen, dining room, staff restroom, resident private bedrooms and bathrooms. During the tour, LPA observed (2) caregivers present wearing mask. LPA observed (2) residents in the common area watching television, (3) residents alone in their private rooms and (1) resident to be in their private room with a nurse. LPA observed the kitchen to have sharps and medication to be locked and secured. LPA observed the facility to have 2+ days of perishable and 7+ days of nonperishable foods. LPA observed fire extinguisher to be last serviced on 10/14/2022. LPA and Asst Admin completed the post-licensing inspection tool and facility was found to be in compliance. LPA conducted a file review of (1) out of (6) residents files and (2) personnel files. As a result of today's inspection, no deficiencies cited. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Mar 14, 2023

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Michael Hood met with applicant, Karl Ramos, to conduct a Pre- Licensing visit. This application is a change in ownership. This address is currently licensed as NORTH AVENUE VILLA Facility #: 347003843. The facility has a fire clearance for six (6) bedridden residents. Applicant holds a current administrator certificate (#6063204740 with expiration date 7/26/2024). LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and four (4) bathrooms for resident use. LPA observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 115 degrees F. LPA checked the kitchen area for the ability to prepare and store food. LPA observed at least a 2-day perishable and 7-day nonperishable food supply at the facility. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home are operational. LPA reviewed two (2) resident files and two (2) staff files. LPA observed during visit that one (1) fire extinguisher needs to be serviced, and files for residents were missing items. LPA indicated all the above observations need to be fixed and facility will send corrections to CCLD within 7 days from today's date. Component III was waived. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval once requested items have been received. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 13, 2022