In R Great Hands - Montevideo

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Joana Crisostomo. Assistant Administrator (AAD) Denise Molde arrived at approximately 12:00 p.m. and the purpose of the inspection was discussed. During the inspection, LPA and Staff Crisostomo conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following: This is a one-story home with five resident bedrooms, one staff bedroom, three bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPA observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 116.2-116.6 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Medication was observed to be centrally stored and locked. LPA reviewed five of five resident files and one staff file. Two of three staff files requested for review are not being maintained at the facility and were not available for review; a Deficiency was cited on today’s date. One of one staff file reviewed did not contain any documentation for initial staff training or staff training conducted in the past year and AAD was unable to provide LPA with a copy of staff training conducted; a Deficiency was cited on today’s date. LPA interviewed two residents and two staff. (Cont. LIC809-C) Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Dec 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 12/9/24. LPA arrived unannounced and met with Staff. The backup administrator, Denise Molde, arrived shortly to assist with the visit. The facility is licensed to served 6 residents, ages 60 and over, of which 4 may be non-ambulatory. There is an approved hospice waiver for 4 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed: Infection Control: Facility has an Infection Control plan and are continuing to clean and disinfect the home. They are using appropriate hand hygiene and wearing gloves while assisting residents. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are no residents utilizing oxygen at this time. Facility has the required amount of liability insurance coverage. Physical Plant & Environment Safety: The facility consists of 5 resident rooms, 2.5 bathrooms, living room, dining room, kitchen, laundry room, and attached garage. The hot water temperature was measured over the required range of 105-120 degrees F. There are no swimming pool or bodies of water on the premises. The fireplace is adequately screened. There are smoke and carbon monoxide combo detectors located throughout the home. LPA observed knives stored in the dishwasher and not locked. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Staffing: The facility has sufficient staffing to meet the needs of the residents. All staff members have current CPR & First Aid certificates. Personnel Records-Training: LPA reviewed 3 Staff files. The administrator's (Riza In) certificate expires on 6/26/24 but verified the renewal has been submitted prior to expiration. Staff have fingerprint clearance and associated to the facility. Staff files have the required documents such as personnel record, health screening with TB results, and dementia care training. Resident Records-Incident Reports: LPA reviewed 5 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, appraisal/needs and service plan, and personal rights form. Resident Rights-Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff. Planned Activities: Facility has sufficient space to provide indoor and outdoor activities to accommodate residents. Incidental Medical and Dental: LPA reviewed medications for all 5 residents and there were no discrepancies found. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Emergency procedures are indicated on the form. Disaster drills are conducted quarterly. Residents with Special Health Needs: Facility accepts and retains residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. There are currently no residents with a prohibited or restricted health condition. Deficiencies are issued on the LIC809D. An exit interview was held. A copy of this report along with appeal rights was given to D. Molde.the state’s words, verbatim · CDSS document, Dec 9, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Resident not assisted in timely manner

An unannounced Complaint Investigation was conducted by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above for the purpose of delivering findings. LPA met with Staff Tristan Raquipo. During the course of the investigation, LPA interviewed facility staff, Resident 1 (R1), and R1’s Responsible Party (RP), regarding Resident 1 (R1) not being assisted in a timely manner. During interviews, three out of three staff denied not assisting resident in a timely manner. Per Staff 1 (S1), staff check on residents periodically, however checks are not on a set schedule, and are not documented. S1 stated R1 informed RP they sustained an unwitnessed after leaving the facility on 8/26/22 and stated there was no evidence or noise to alert that R1 fell. Per S1, R1 told RP that they did not inform anyone they had sustained a fall. (Cont. LIC9099-C) Unsubstantiated LPA interviewed R1’s RP, who stated that on 8/26/22, R1 was picked up from the facility by a family member to go to speech therapy and there was no indication R1 had fallen. Per RP, R1 also did not inform them of the fall. RP stated that later the same day, R1 informed another family member of the fall, and the family member then informed RP. RP stated R1 requested to go to the hospital, and they transported R1 to the hospital, where R1 was diagnosed with a hip fracture. During their interview, R1 confirmed they had sustained an unwitnessed fall at the facility, while attempting to get to the restroom. R1 stated they became dizzy and fell but did not alert staff to the fall and staff were unaware they had fallen. Per R1, they did not alert staff or ask for help because they did not need staff assistance and were able to get back on their feet independently. Due to conflicting information received during interviews conducted, LPA is unable to determine if resident was not assisted in a timely manner. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 22-AS-20220831133413

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Case Management inspection in conjunction with investigation into complaint number 22-AS-20220831133413. LPA met with Tristan Raquipo and explained the purpose of the inspection. During the course of the investigation, deficiencies were observed. Upon request of Resident 1’s (R1’s) file, facility was unable to provide any documentation pertaining to R1. During interviews, Staff 1 (S1) stated R1 was at the facility from 8/17/22-8/26/22 and R1’s responsible party had taken all documentation upon discharge on 8/26/22. Per California Code of Regulations Title 22, 87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff; additionally per 87506(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. Based on observations made during this inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Feb 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Mar 1, 2024

The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidence by: During the course of complaint investigation, facility was unable to provide any documentation pertaining to R1, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Licensee and Administrator will submit a statement that they have read and will be in compliance with regulation to LPA via email by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(e) · Plan of correction due date: Apr 1, 2024

Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidence by: During the course of complaint investigation, facility was unable to provide any documentation pertaining to R1, which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Licensee and Administrator will submit a statement that they have read and will be in compliance with regulation to LPA via email by POC date.