JCP Cottage

Type of visit: Required - 1 Year

On 11/07/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Frisco Sanry and introduced self and stated purpose of the visit. LPA was informed that there are currently 4 residents in care. The facility has 6 bedrooms, 2 bathrooms, kitchen, dining area, living room, laundry, backyard, and attached garage. LPA completed a walk through of facility and review of records. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.3 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, emergency disaster plan, CCL complaint poster and ombudsman were posted in a common area. LPA observed an outdated emergency disaster plan last reviewed on 10/19/2021. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications was observed locked and inaccessible to residents. There is no swimming pool, bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right side of the house that leads into the backyard and one shed used for storage. Record Review: LPA reviewed staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed incomplete files for residents. Deficiency issued. LPA observed that the facility did not have an updated infection control plan. Deficiency issued. LPA observed that the facility does not maintain a log for the emergency drills performed. Deficiency issued. Deficiencies and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to Administrator, Frisco Sanry.the state’s words, verbatim · CDSS document, Nov 7, 2023

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Administrator did not designate appropriate personnel in their absence Facility is not meeting food service requirements Resident's property was not safeguarded Facility does not provide activities for residents

Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegations. Upon arrival, LPA Williams introduced herself to Administrator, Frisco Sanry, who was also informed of the purpose of the visit. The investigation consisted of direct observations, records review, and interviews with staff and residents. In regards to allegation #1, LPA Williams interviewed Staff #1 (S1) who stated that a Designation of Facility Responsibility form (LIC 308) was submitted to the regional office prior to S1 leaving the country from 11/15/2021-11/29/2021. LPA Williams confirmed that the form was received by the regional office on 11/9/2021. In regards to allegation #2, LPA Williams interviewed S1, who stated that Staff #2 (S2) and Staff #3 (S3) were trained on providing adequate food service to the residents. S1 stated that prior to S1 leaving the country, S1 observed that S2 and S3 provided adequate food service; however, S1 stated that S1 could not detail the food service provided by S2 and S3 while S1 was away. S1 denied that the facility is not providing adequate meal Unsubstantiated food service provided by S2 and S3 while S1 was away. S1 denied that the facility is not providing adequate meal portions, and stated that the residents receive three meals a day plus snacks in between meals. S1 denied that there are expired foods in the facility's food supply and that the meals are nutritious with various meats and vegetables provided to the residents. LPA Williams interviewed Resident #1 (R1) and Resident #2 (R2), who both stated that the facility is providing adequate food service. In regards to meal portions, R1 stated that they can be small at times; however, second portions of food may be requested. LPA Williams observed a sufficient supply of perishable and non-perishable food supply. LPA Williams also observed that items in the food supply did not appear expired nor unpalatable. In regards to allegation #3, LPA Williams interviewed S1 who stated that there was an incident in the past where resident's clothing items were co-mingled in the laundry; however, S1 stated that there have been steps taken to prevent another incident such as this. S1 denied that the residents property is not being safeguarded. LPA Williams interviewed R1 and R2 who denied that their property is not being safeguarded. In regards to allegation #4, LPA Williams interviewed S1 who stated that there are various activities for the residents, including board games, puzzles, and exercising. LPA Williams interviewed R1, who stated that the facility does provide activities for the residents. LPA Williams interviewed, R2, who stated that they choose not to participate in activities provided by the facility. Based on evidence obtained during today’s visit, LPA Williams has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to the Administrator at the completion of the visit.the state’s words, verbatim · CDSS document, Dec 6, 2021 · control 18-AS-20211129131125

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Williams identified herself to Administrator, Frisco Sanry, who was also informed of the purpose of the visit. Sanry confirmed that the facility currently has no positive COVID-19 cases. During the inspection, LPA Williams interviewed the Administrator pertaining to the facility's infection control measures and inspected the facility for regulatory compliance. LPA Williams observed appropriate postings in the facility, including COVID-19 symptoms postings and visitation policies, which were in accordance with the Department's guidelines. LPA Williams observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA Williams observed that the facility staff were wearing face coverings and the Administrator stated that the facility requires all visitors wear face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. Based on interviews and observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was provided to Sanry at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Dec 6, 2021

Allegation investigated: Staff did not ensure facility was maintained at a comfortable temperature Staff failed to meet resident health needs Resident sustained stage four pressure injury while in care.

Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation on the above allegations. The LPA was greeted by staff, Florencio Munar, and later me with Administrator, Frisco Sanry. Lee was informed of the purpose of the visit. Pertaining to the allegation, "Staff did not ensure facility was maintained at a comfortable," it was alleged Resident One (R1) was always cold while in care of the facility. The Department commenced the investigation of the allegation on January 08, 2020. At time of visit it was revealed R1 passed away on October 24, 2019 and so an interview could not be conducted. Resident interviews were conducted though unsuccessful; due to resident cognitive decline, information could not be obtained. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. With regard to the allegation, "Staff failed to meet resident health needs," it was alleged Residents One (R1) and Two (R2) were not turned regularly by staff members. Prior to the commencement of the investigation it Unsubstantiated was revealed R1 and R2 had passed away and so interviews could not be conducted. Hospice medical records were obtained for each resident. Records show neither residents were diagnosed with pressure injuries; however, staff were instructed to reposition/turn both residents regularly. R1's medical records indicate red skin noted to their coccyx. Daily notes were reviewed for each resident. Notes did not indicate R1 was or was not repositioned/turned regularly. Resident interviews were conducted though unsuccessful; due to resident cognitive decline, information could not be obtained. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time. With regard to the allegation, "Resident sustained stage four pressure injury while in care." it was alleged Resident Three (R3) sustained a stage four (4) pressure injury while in care of the facility. Prior to the completion of the investigation it was revealed R3 had passed away and so an interview could not be conducted. Medical records were obtained; an Interdisciplinary Plan of Care Update/Meeting revealed R3 was receiving hospice services for a stage II pressure injury to their Coccyx. R3's records revealed the resident was hospitalized on November 22, 2019 and diagnosed with a stage III to IV sacral decubitus ulcer prior to discharge. R3's Hospice notes reveal the initial injury was a result of incontinence and poor eating. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Sanry, in which this report was reviewed and a copy provided.the state’s words, verbatim · CDSS document, Oct 11, 2021 · control 18-AS-20200102113339