Jaj Residential Care for Elderly

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) De Leon arrived at 2:15 pm to conducted a Case Management Annual Continuation visit to the facility above. LPA met with Licensee/Administrator Joe Castillo and explained the purpose of the visit. LPA returned to the facility to complete the annual visit. LPA reviewed staff files, Staff Training Records and conducted interviews on staff and residents in care. Staffing: The facility employes 4 staff and 1 Administrator. Staff records are kept confidential. Staff files were reviewed for 1st Aid/CPR, Health Screening with TB results, Finger print/Back ground clearances, Personnel Record/Applications, Reporting Abuse, Criminal Record Statement. At 3:30 PM LPA noted that 2 out of 5 staff were missing original TB results and 1/5 staff was missing original Health Screening. Administrator has misplaced original documents and has made appointments for 2 staff to get a new TB result, 1 staff to get a new health screening and will provide all copies to CCL. Personnel Records & Training: Staff files and training records were reviewed on this visit. All 5/5 staff had completed required 2023 Annual Training of 20 hours on general requirements, Dementia Care, Restricted Health Conditions, Postural Supports and Hospice Care. Licensee/Administrator provided LPA will copies of all missing residents forms from last visit. Exit interview completed, Deficiency cited, copy of report and appeal rights printed/emailed to Licensee.the state’s words, verbatim · CDSS document, Jun 26, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 12:00 pm to conducted a 1 year annual visit to the facility above. LPA met with Licensee/Administrator Joe Castillo and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan, Emergency Disaster Plan and provided plans to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer and symptom screening. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. New residents are tested and negative results received before residing in the facility. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environment Safety: The facility is a 5 bedroom and 2 bathroom currently occupying 5 residents and employs 5 staff with 2 live-in staff using 1 bedroom and 1 bathroom. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has a carbon monoxide detector and smoke alarms. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The showers have non-skid textured floors. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions and well lit. Disinfectant, cleaning solutions and poisons are locked and inaccessible to residents in care. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 06/15/2024. The facility is approved for a capacity of 6 Non-Ambulatory and has a current Hospice wavier granted for 1. Staffing: The facility employes 4 staff and 1 Administrator. Staff records are kept confidential. Staff files were not reviewed on this visit and will be done on the annual continuation visit. Personnel Records & Training: Staff files and training records were not reviewed on this visit and will be reviewed on the annual continuation visit. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before excepting them into care. The Facility does not handle cash resources for any resident in care. Facility does submit incident reports to the department when required. 1/5 Admission Agreements were missing, 4/5 ANS were not up to date. 2/5 needed TB result on file. Administrator will send copies of missing forms to LPA after retrieving additional files from off site office. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license along with CCL reports and PIN's were posted. Visitation policy is posted at entry. The facility has a working telephone for resident use. Internet is provided with confidentiality and privacy for each resident. Planned Activities: The facility offers activities to all residents in care. The facility has a monthly calendar with all activities posted. The facility also offers additional activities to include books, magazines, newspapers, television, group discussions and communications, games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for residents in care. Modified diets prescribed by a physician are followed for those residents in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices. Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for the Centrally Stored Medication and Destruct Records (CSMDR) and Medication Administrator Records (MAR). Records were up to date, legible and given as prescribed. LPA completed a full audit on two residents medications, all medications were in original containers, prescription labels were not altered, doctors orders were present and dispensing instructions were followed. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills no documentation was present, Licensee will provide LPA records of quarterly drills. The fire extinguishers were charged and last inspected 02/22/2023. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency and a file with residents emergency information is present for each resident in care. Residents with Special Health Needs: All items that could pose a danger, sharps, cleaners were locked and in accessible to residents in care. The facility does not have delayed egress. The facility has 1 hospice residents in care. Hospice care plan was missing in resident file and Licensee will provide a copy to LPA once retrieved from off site office. The facility does not currently have residents on any Home Health services. LPA will return at a later date to complete annual for staff records, staff training and interviews. Exit interview conducted and copy of report printed for Licensee/Administrator.the state’s words, verbatim · CDSS document, Jun 19, 2023

Allegation investigated: Staff do not ensure the residents are properly fed while in care

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings. LPA met with Administrator Joe Castillo and explained the purpose of the visit. LPA Darlene Chavez conducted an initial complaint visit on 04/23/2021. LPA Chavez requested documentation. LPA De Leon conducted an annual visit on 06/16/2021 checking on food supply around 10:30 AM. The food supply was within the requirements of regulation. LPA De Leon conducted subsequent complaint visit on 05/05/2022 at 2:00 PM. LPA checked all of the facility food supply at 2:30 PM, the facility had 2 plus days of perishable and 7 plus days on non-perishables foods for residents. Unsubstantiated LPA verified no residents were on special diets. The facility had a back-up emergency food supply with water for residents in care. LPA interviewed Administrator at 2:50 PM and facility staff at 3:10 PM. On the allegation: Staff do not ensure the residents are properly fed while in care. Based on LPA observation on 06/21/2021, on 05/05/2022 visits and staff interviews the facility has an adequate food supply to meet regulation requirements with residents in care. The grocery shopping is conducted weekly on Wednesdays and on Monday's to keep a fresh fruit supply on hand at all times with 2-3 fruits for variety purchased as well as maintains a supply of canned and frozen fruits. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report emailed to Administrator/Licensee.the state’s words, verbatim · CDSS document, May 5, 2022 · control 29-AS-20210421102410

Type of visit: Required - 1 Year

Licensing Program Analyst's (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 05/05/2022 at 2:00 PM. LPA met with Joe Castillo Administrator and explained the purpose of the visit. Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in, symptom, and temperature screening. All documentation is kept on a clipboard and filed in binder daily. The entry station has hand sanitizer along with a thermometer. The facility has a large living room area that is used for activities and exercise, all areas are spaced to accommodate as much space as possible for social distancing. All equipment and PPE supplies are kept in a cabinet accessible to all staff. Medications are kept in a locked cabinet in the kitchen area. The kitchen area has a dining area to accommodate distancing between residents when eating meals . The staff screen residents for symptoms and temperature 1 x's a day. Increased monitoring is conducted if any change of condition is noted or any residents is showing any signs, symptoms or has a temperature, change of conditions are documented and kept on file. Signs are posted on the hallway walls through out the facility regarding Covid-19. All required postings are hung in common areas of the facility. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility has several areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. The Facility has hand sanitizer located thorough out the house. Staff, residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. Continued 809-C The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility staff will be assigned to only work with those individuals. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 3 resident bedrooms, 1 resident restroom and 1 live-in staff room. Restrooms are disinfected after use. Signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Trash bins had tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. The facility has not been fitted tested for N95 masks and LPA explained in an outbreak the facility would need to be wearing N95 and CAL OSHA requires the fit testing of those masks. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Furniture has been moved around to accommodate social distancing between staff and residents. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap and paper towels. Staff and resident records are kept locked in cabinets. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by those agencies. Continued 809-C The facility had plenty of perishable food for 2 plus days and non-perishables for 7 plus days. The facility maintains an emergency food and water supply. Administrator Certificate is valid. Smoke detectors are hard wired through-out the facility. Fire Extinguishers are charged and inspected annually. No deficiencies observed during the visit and all infection control protocols are implemented and followed. Exit interview completed and copy of report given to Administrator.the state’s words, verbatim · CDSS document, May 5, 2022