Hidden Glenn Senior Living II

Type of visit: Case Management - Deficiencies

On 4/15/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced case management visit to address a deficiency discovered when delivering an amended report for complaint control number 18-AS-20241121100930. LPA met with Executive Assistant (EA), Cynthia Valencia who was informed of the purpose of the visit. During today's visit, LPA delivered an amended report substantiating allegation, “Facility staff do not ensure that a comfortable temperature for residents is maintained at all times”. As a result, the facility will be cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted an a copy of this report was reviewed and provided to EA Valencia along with Appeal Rights.the state’s words, verbatim · CDSS document, Apr 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b) · Plan of correction due date: Apr 25, 2025

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidenced by: Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met and the allegation “Facility staff do not ensure that a comfortable temperature for residents is maintained at all times” from complaint control number 18-AS-20241121100930 was ultimately substantiated. This poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: EA Valencia reported the furnace has been replaced and smart thermostats have been placed in the facility to allow the facility administrator/management staff to program and control the temperature remotely. POC met.

Allegation investigated: Facility staff do not ensure that a comfortable temperature for residents is maintained at all times

On 4/15/2025, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to the facility to deliver amended findings for the above allegation. LPA met with Executive Assistant (EA), Cynthia Valencia who was informed of the purpose of the visit. It was alleged the temperature in the facility is below 68 degrees Fahrenheit (F) and the dining room is very cold at 8:00 a.m. during breakfast. On 11/26/2024, LPA visited the facility and was informed the facility's furnace is currently being replaced by a Heating, Ventilation, and Air Conditioning (HVAC) contractor. LPA conducted a witness interview with the HVAC contractor who reported they were present at the facility to replace the old furnace. The witness added the current furnace is working properly and it is being replaced simply because the equipment is old. LPA was informed the facility has a central AC and heating system controlled by two thermostats. *This is an amended version of the original report. Substantiated On 11/26/2024 at 7:47 a.m., LPA toured the facility with Facility Nurse, Veronica Lukasik and observed the thermostat near the medication room set at 70 degrees F and another one near the activity room set at 69 degrees F. At the time, the weather outside was 54 degrees F. Administrator, Brigitta Lofvendahl was interviewed and reported the thermostat is set at 70 degrees F to try to maintain a comfortable temperature for all residents. Administrator added anytime the thermostat is set above 70 degrees F, some residents complain the temperature in the facility is too hot. Administrator explained the facility had additional funding so they decided to replace the furnace since it is approximately 10 years old. LPA reviewed the HVAC estimate dated 7/1/2024. Administrator added the new AC and heating system will include smart thermostats that will allow Administrator to adjust the temperature remotely. Two (2) care staff were interviewed and reported residents have not complained to them about the temperature in the dining room or facility being too cold in the mornings. Five (5) residents were interviewed and corroborated the allegation. As a result, Administrator Lofvendahl reported they would increase the temperature on the thermostat. Based on LPA’s interviews conducted and records reviewed, 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, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided to EA Valencia. *This is an amended version of the original report.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 18-AS-20241121100930

Allegation investigated: Facility did not safeguard resident's belongings. Resident did not receive mail. Resident was not treated with respect by staff.

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint investigation visit. LPA Silveira introduced themselves, met with Receptionist Maria de Jesus Bejar Flores and disclosed the purpose of the visit. The purpose of the visit was to deliver complaint findings for the above-mentioned allegations. The Department’s investigation consisted of interviews with residents, staff and outside sources, as well as a facility records review. On 11/18/2021, it was alleged that Resident #1 (R1) did not receive mail and that the facility did not safeguard R1’s belongings. It was alleged that R1 had food items and mail stolen from them. (CONTINUED ON NEXT PAGE, LIC 809-C) Unsubstantiated (CONTINUED FROM FIRST PAGE, LIC 809) Department interviews with four (4) residents who resided at the facility during November 2021 revealed that the residents did not have any complaints regarding items or mail being stolen from them. Interviews with outside sources revealed that there were no reports or concerns with the theft of items or mail from residents. Interviews with facility care staff who have worked at the facility since November 2021 revealed that staff have never witnessed items being stolen from residents and residents have never reported items or mail being stolen to staff. An interview conducted with R1 on 08/16/24 revealed that R1 did not have concerns regarding items or mail going missing and expressed that they liked living at the facility. Finally, an interview with the Administrator also revealed that in August 2021, a complaint was filed with the local post office regarding facility mail not being received. The interview also revealed that there was a facility policy regarding food items having to be located in the kitchen due to pest control issues, which may have caused confusion for R1. There was not enough evidence to support these allegations. It was also alleged that R1 was not treated with respect by staff. An interview with R1 on 08/16/24 revealed that R1 stated that the staff at the facility are “really good” and that staff treat them with respect. Interviews with four (4) residents who have resided at the facility revealed that no residents had complained about being mistreated by staff, and all residents liked living at the facility. Interviews with outside sources revealed that there are no concerns with how staff treat residents. Interviews with facility staff who have worked at the facility since 11/2021 revealed that staff have not witnessed other stall mistreating residents. Department interviews with the Administrator and Facility Nurse revealed that during November 2021, R1 was experiencing health issues that may have temporarily affected their mental health. Finally, a review of a medical record dated 04/11/2024 revealed that R1 was diagnosed with a depressive disorder that is recurrent and severe. There was not enough evidence to support this allegation. Due to a lack of corroborating evidence, the allegations that the facility did not safeguard resident’s belongings, the resident did not receive mail and the resident was not treated with respect by staff are unsubstantiated. LPA Silveira conducted an exit interview with Maria. At the time of the exit interview Maria was provided with a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 03/22). The signature on this report acknowledges receipt of the rights.the state’s words, verbatim · CDSS document, Aug 28, 2024 · control 08-AS-20211108114118

Type of visit: Required - 1 Year

On today's date 07/11/24 at 11:30am Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for the purpose of conducting a 1 year required visit/annual inspection. LPA met with Executive Director Brigitta Lofvendahl and explained the purpose of the visit. At the time of the inspection there were 2 staff and 13 residents present. The facility is licensed to serve residents age 60 and over, 15 non ambulatory of which 15 may be bedridden. The facility has an approved hospice waiver for six (6). At this time there are currently no residents receiving hospice services. Below are the observations made during today's visit: The facility is a single story structure with (7) combined bedrooms and bathrooms, dining area, front and back patio, kitchen, living room, medication room, and garage which is used to store the laundry appliances, generator and extra food. The facility was observed to be clean and clutter and odor free. The call lights were tested and observed to be operable. LPA observed all toxic chemicals and other hazards/sharps to be inaccessible to residents. The medications are locked inside the medication room. The facility food supply met the requirements of a 2 day supply of perishable and a 7 day supply of non perishable food items. The hot water temperature was tested and found to be within regulatory limits, measuring at 106.5 degrees Fahrenheit. The facility has (2) fully charged fire extinguishers fully charged. The emergency drills are conducted quarterly, the last drill was conducted on 4/16/24. Staff present were observed to have obtained criminal record clearance and to be associated to the facility. Staff present were observed to have valid CPR/First Aid certification, and possess a valid Administrator certificate which expires on 04/16/2025. Resident files were observe to have the required documentation such as physician's report, appraisal, and admissions agreement. The last fire inspection was conducted on 12/14/23. The smoke and carbon monoxide detectors were tested and found to be operable. The facility was observed to have the required postings such as personal rights, CCL complaint poster, theft and loss policy. Based on today's inspection, no deficiencies were observed during today's visit. The facility was found to be in compliance with California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of the report and LIC 811 was provided to the Executive Director, Brigitta Lofvendahl .the state’s words, verbatim · CDSS document, Jul 11, 2024