Jewell Home Care

Type of visit: Case Management - Other

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to amend a previous report. LPA met with staff Medline Cole and explained the purpose of the visit. A D page of a report from 6/17/26 didn't have the language describing the condition of the facility. The amended report has it included. To summarize, there is a bedridden client in a facility without a clearance for bedridden. LPA did a physical observation of the facility, its clean and traffic areas are well lit. residents are responding positively to questions about thier care. A copy of the report was read and given to the facility staff, a copy will be emailed to the administrator using the email on file. exit interview conducted.the state’s words, verbatim · CDSS document, Jun 23, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived to the facility at 11am, on 6/17/26 to conduct a case management related to deficencies of the Fire Clearance. The Administrator is out of the facility responding to an emergency, the staff attempted twice to get in contact with her, the LPA met with the aviallible staff to explain the purpose of the visit. The department was made aware of a county fire department report which did not pass the facility on a capacity to care for bedridden on its most recent fire inspection, A citation for failing to pass fire clearance and associated immediate 500$ civil penalty will be issued on a following d-page and lic421. The LPA gave guidance that there were observed similar citations in the facility history and the facility should know well the responsibilities and requirements at this point. There is at least one bedridden client in the home currently. One resident on hospice. LPA interviewed 3 clients, they are responding postiviely to questions about thier care. The report outlined two plans of compliance. The facility is in pursuit of one of the plans which will result in fire clearance for at least one bedridden. When asked about progress updates to that pursuit, the LPA was told by staff that a contractor will be arriving to take an estimate of the work today. Citation was issued in connection with this visit, appeal rights were provided, a copy of the report was read and left with a representative of the administrator, a copy of the report will be sent to the administrator via email to the address on file. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80020(a) · Plan of correction due date: Jun 18, 2026

80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. **This report is amended, to include the following statements which describe the condition of the facility that is out of fire clearance.** This requirement was not met as evidinced by: The LPA's observation,, and interview with staff where 1 out of 5 clients is described as not being able to rotate in bed without assistance. record review of the facility license showed no clients may be permited as bedridden. Not following this requirement presents a immedate risk to the health saftey and personal rights of clients in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Provide the LPAs a written plan and projected timeline for the steps nessecary to achieve fire clearance approval by poc date, 6/18/26. Provide a monthlly status update on elements of that plan thereafter until completion. Albert.johnson@dss.ca.gov and Noel.wolfpetersen@dss.ca.gov

Type of visit: Case Management - Health Checks

Licensing program analyst, LPA, Noel Wolf Petersen, arrived unannounced to the facility to conduct a case management related to a recent report by the stockton fire department, LPA met with the administrator Monica Plowden by phone, to explain purpose of the visit. LPA toured the facility with the care giver on staff. There are 4 residents in the facility, 1 is obviously ambulatory(R1), the remaining 3 are in bed. LPA asked 2 residents in bed to demonstrate that they can rotate, two are able to rotate unassisted(R2, R3). Resident(R4), not able to Rotate independantly, resident(r4) in interview made the statement that he needs assistance with rotation. Seperately, care staff in interview made statement that r4 needs assistance with rotation. Administrator provided a statement that there has not been a 602 assessment for the r4, and emailed the LPA a doctors note stating that the client is considered nonambulatory as opposed to bedbound. Administrator provided a statement that an a 602 assessment is scheduled for R4 on 5/12/26. regarding a previous citation for fire clearance that was issued regarding r4, the LPA believes that POC is still being addressed at this time in good faith. Licensee is unsure at this time if she will make the corrections from the fire department to conform to bedridden status, LPA is asking for the delivery of concrete decision about whether to pursue the bedridden clearance on 5/13/26 and a copy of the R4's upcoming 602 to be sent to the LPA (noel.wolfpetersen@dss.ca.gov). LPA gave guidance that in choosing not to pursue a bedridden fire clearance, the licensee should immediately assist R4 with alternate accommodation. No citations issued as part of this visit, a copy of the report was read and given to the administrator via email signed by designated signatory, Medline cole, exit interview was conducted.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 will be provided to the licensee. Parties in attendance of this meeting are documented on the LIC 9111. On April 15th 2026, a meeting was held at 2pm regarding recent noncompliance with regulation at the facility Jewell Care Home with 3 agenda items: Incident: In the past year, a client of the facility was hospitalized in relation to widespread bruising with an unknown origin. Shocking to the department was that there was documentation from the staff that it was internally reported but the internal reporting didn’t make it to Licensing. Staffing: As part of an investigation by the department into the above event, the staffing of the facility appears to have one staff present for all of three of both Saturday and Sundays shifts. It's unclear that the staff receive adequate coverage for breaks and adequate uninterrupted rest between shifts where they are expected to not be on call. Administrator staffing: Separate from adequate numbers of staff, its unclear the administrator is spending adequate time in the facility to observe the staff performing basic functions, training, and assessing staff. Continued on C page Issues discussed related to the above include: Facility plans regarding mandated reporter training and staff coverage Staffing in the facility regarding incontinance/rotation, hiring a new staff Numbers of bedridden currently at the facility, how does hospice count for bedridden? Quarterlys, where the implementation of the agreed upon section below will be observed by an LPA. During the meeting, the facility agreed to the following: (highlighted are standard asks) 1. Submission of LIC 500 Personnel Summary for supervisory changes facility to include Administrator presence with no less than 40 hours per week by 4-22-26. 2. Conduct Mandatory Reporter training within 6 months then annually 3. Provide a Plan for the administrator to be observing and assessing the staff in the performance of their duties for the facility by 4-22-26 Provide a job posting for a new hire to 4-22-26 CCL will: Conduct unannounced quarterly visits to monitor the overall compliance. Licensee has been advised that failure to complete the above agreed upon actions by the dates will result in this Department taking action(s). During these visits, the Department will focus its review on the following areas in addition to the above: ~Individualized Needs and services plans updated quarterly for all clients documenting the facilities obligations, ~Contracts on file describing obligations as needed for clients with Home Health and Hospice Care, ~Staff knowledge regarding reporting requirements, restricted and prohibited care conditions In the event that the Department determines that the licensee has violated the law/regulations or is inadequately implementing the approved plans, the Department, in its discretion, may seek formal legal action or other appropriate administrative action. The meeting concluded at 2:40pm. A copy of the report and the 9111 were read to the licensee and an exit interview was conducted via telephone. a copy of this report and the 9111 were sent electronically for signature.the state’s words, verbatim · CDSS document, Apr 15, 2026

Type of visit: Case Management - Other

Licensing Program Analyst Noel Wolf Petersen arrived unannounced 10:45 am to the facility to collect some documents related to a recent complaint and its case management. Met with licensee administrator Monica Plowden, explained purpose of visit. During the visit, The LPA was provided a home health care plan for the 1 resident who recives home health services. During the visit, The LPA was provided a drivers license for the person identified as Diane Hace, drivers licance asserts Luvina Addison has the middle name Diane, hace from a current marriage. Luvina Addison is gaurdian associated. 5 residents are currently in the facility, and 5 at the time of the interview in the departments report, LPA confirmed it the same five residents with staff. 1 is reciving hospice care. LPA assessed the other 3 for the ability to turn in their bed, 1 resident is out of the facility currently at the hospiital. The 2 clients observed are able to rotate under their own power. The last client is not able to rotate on his own per the staff stating he does need assistance being rotated and cannot do it himself. LPA observes the Clients is equipped with full bed rails. Doctor signed 602 says nonambulatory, and has a commented section for needing assitance with getting into a electric wheelchair and care for ulceration on the skin(Toe Area). Given the risks of bedcare identified on the 602, the LPA's observation of the weakness in using the bedrails, and the staffs statement he needs assistance with rotating, LPA asserts the client meets the title 22 definition of bedridden, not being able to rotate in bed indepentantly. fire clearance for Jewell Care home is for 6 ambulatory, up to 4 may be nonAmbulatory, none may be bedridden. Continued on c page LPA gave guidance the facility should make a plan to meet the clients needs(become fire cleared for at least 1 bedridden) or immediately assist him with finding alternate lodging. Facility has 2 bedrooms that have doors to the exterior. during the visit, Licensee provided the Hospice operation section of plan of op is ammended. Citation and immediate civil penalty were given as part of this visit, appeal rights were provided. A copy of the report was read and a left in the care of the adiministratotf. Exit interveiw conducted.the state’s words, verbatim · CDSS document, Mar 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Mar 14, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons This requirement was not met as evidinced by: The LPA's observation that 1 of 5 clients makes use of full bed rails, and interview with staff where the client is described as not being able to rotate in bed without assistance. record review of the facility license showed no clients may be permited as bedridden. Not following this requirement presents a immedate risk to the health saftey and personal rights of clients in care.the state’s words, verbatim · CDSS document, Mar 13, 2026

Plan of correction: Licensee should make a plan by the poc date to either pursue a fire clearance that includes bedridden, or immediatly seek a new housing arragement for the affected resident. LPA will be informed of the plan by end of day 3/14/26.

Allegation investigated: Resident sustained unexplained injuries

On 2/25/26 at 6:00pm, LPA Wolf Petersen arrived to deliver the findings of a complaint. LPA met with administrator Monica Plowden, by phone to explain the findings of a departmental report concerning the above allegation(s). By interview it was learned that on 10/23/25, R1 had a bathing visit from an aide who provided a statement that they did not observe bruising at that time, a follow up visit occurred on 10/28/25, in which the aide observed bruises on the lower right and left sides of her face, right neck, upper right and left arm, right forearm, and lower leg left. 2 staff of the facility and the administrator provided statements that they did not know the origin of the bruises. S2 noticed a bruise on R1's face on 10/27/25, which was not present on 10/24/25. S3 was the only staff working 10/25/25 and 10/26/25, and provided a statement denying unintentionally or intentionally causing r1's bruising. Additionally, S3 reported that they failed to notify the Administrator of the bruising, stating "they were waiting for hospice to come by to report it". Continued on C-page Substantiated According to interviews with both staff and the Administrator, the staff are not present when the residents are bathed by an outside agency. According to interview with S3, the believed that the aide caused the bruising but failed to report. A record review of R1's hospital visit 10/28/25 in relation to the bruising, noted the bruising appeared to be in a grabbing pattern to R1's right and left upper extremities at distal biceps, bilateral shins, and upper chest, secondary to handling r1 for care. R1 was not on any medications that would cause bruising. Observations of R1 detail they are bedbound and depend on caregivers for all activity's of daily living. R1 is nonverbal and its expression imposed difficulty on explaining how they sustained the injuries. Based on the departments observations and interviews and record review which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided. A copy of the report was read, was given to the administrator.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 27-AS-20251113172249

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Feb 26, 2026

87464 (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by: R1 was observed to have significant bruising on the body, presumably from either the Aide providing baths unsupervised by the facility staff, or by personal care being provided to a bedridden person with inadequate staffing to provide the care necessary to safely meet the needs of R1.In either instance, the facility failed to provide the necessary care which poses an immediate risk to the health and safety to clients in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: No imediate POC: the resident has alreaty been removed from the facility. Licensee should provide training on the facilities care and supervision policies annually. Licensee will update their Plan of Operation to address this in detail by 3/6/26. Call the LPA in advance of this date if there is more time needed.

Type of visit: Case Management - Deficiencies

On 2/25/25 at 6:30, LPA Wolf Petersen arrived to conduct a case management related to the findings of a complaint. LPA met with administrator Monica Plowden by phone to explain the findings of a departmental report. In interview, staff provided a statement that they were insufficiently following facility procedures and regulatory requirements to report the bruises and follow up with seeking medical attention. In record review of the medical reports generated from the 10/28/25 visit related to bruising, R1 was diagnosed with both a uti and obstruction. LPA gave guidance that staff should document changes in status, to include bruising. If its reasonable to suspect that physical abuse is occurring, the facility should be reporting to licensing, the ombudsman, and local law enforcement within 24 hours via an IR, telephone call and SOC341. If its reasonable to suspect medical attention is required, the facility should be arranging for medical care. Observation of resident and changes in mood, condition or functional ability should be reported to the physician and if necessary appropriate medical intervention sought in a timely manner. Having hospice does not preclude the licensee from seeking timely medical attention. The Department is Requesting the 602, any Hospice Care Plan, and any Home Health Plan, for all residents currently in the facility. Provide to the lpa via email: noel.wolfpetersen@dss.ca.gov. 3/6/25 Citation(s) are issued, A copy of the report was read, appeal rights and the copy of the report was given to the administrator. An exit interview was conducted.the state’s words, verbatim · CDSS document, Feb 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466(a) · Plan of correction due date: Feb 26, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as ...deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: interview where staff had applied an ointment to the bruising, and upon proving ineffective over two applications, reported bruising to the hospice care nurse instead of making arrangements for the client to go the hospital. Record review of the hospice care plan, where severe widespread bruising is not described as a responsibility of the hospice care agency. Record review of a residents medication history, where the client has not taken blood thinners. Not following this requirement poses an immediate risk to the health, saftey, and personal rights clients in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: No Immediate POC required: the resident at risk was already removed from the facility. Licensee will conduct a training on the division of labor for hospice care and the facility, when its appropriate to use the hospice care nurse versus when its appropriate to use medical services. Licensee will update their Plan of Operation to address this in detail. training by 3/25/26. updates to the plan of Op by 3/13/26

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(c) · Plan of correction due date: Feb 26, 2026

87211(c) Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by: interview where a staff had noticed mysterious bruising coinciding with home health aide visits in months previous to a complaint incident in october 2025, record review of the internal staff log where a vague documentation of the event exists in september 2025 and statements by the staff pertaining to the current investigation. Not following this requirement poses a immediate risk to the health, safety, and personal rights clients in care.the state’s words, verbatim · CDSS document, Feb 25, 2026

Plan of correction: No Immediate POC required: the resident at risk was already removed from the facility. All staff shall participate in Mandated Reporter Training . Send the LPA evidince of a training(trainings) scheduled with a contact for a vendored trainer, by 3/25/26

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with staff; later joined by Administrator Monica Ralh. LPA and Staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day nonperishable and two day perishable food supplies. LPA and Staff measured the hot water temperature in resident’s bathroom at 119 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. medication logs. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 09/2025. No deficiencies cited during today's inspection. Exit interview conducted and appeal rights giventhe state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to conduct a case management regarding an incident that occured at Jewell Home Care, the staff had noticed some facial bruising on a client on sunday 10/26/25 that exacerbated into a concerning size and shape by monday 10/27/25, which was reported by a Home Health Aid working for A Plus Prime Care Hospice, INC, a hospice agency, on the 10/28/25 tuesday. Police were called out and Adult Protective Services moved the client. Jewel Home Care is a 6 bed facility for the elderly that includes dementia support with a maxiumum of 3 residents on hospice, there are currently 1 residents with hospice, one has wound care, and 2 non ambulatory residents. LPA Wolf Petersen asked for any documentation regarding the incident in hospice care notes, The facilitiy internal care notes. Document review for the facility internal care notes is sparcely detailed, but indicates that some bruising appears to be recognized in a timing pattern that coincideds with a bathing service performed by a Home Health Aid working for PrimeCare from september on to the present. Interview with the staff does not indicate that they were trained to document changes in status(i.e. bruising), while they are up to date with mandatory training hours and topics of general rcfe care, care specific to hospice clients, and care specific to dementia clients. All staff interviewed denied interacting with the client in a way that would be consistant with the griping of the face pattern of bruising that was observed. All staff interviewed note not being concerned with the bruising until monday morning, and while concerned they decided not to contact the hospice care agency for a variety of reasons,(the hospice nurse will be coming out the next day, the hospice nurse is not willing to do anything) continued on c Page. Client was noted in hospice initial assessment to have a confused temperament and expressive of resistance to being repositioned during diaper changes. Current medication at the time of the incident back to september includes a blood thinner. Facility copies of the Hospice care notes surveyed, does not have any indication of bruising in the narrative section. Hospice care plan revised 10/14/25, indicates that training will be provided on skincare to the family/PrimaryCareGiver, administrator interview provides that the Hospice care plan did not follow through with the training noted on the hospice care plan to be provided by 10/31/25. and was not provided in that time. The LPA is providing guidance that improving note taking procedures for changes of status between shifts and coordinating note taking procedures for changes of status from visiting agency representatives would be a good idea moving forward. Timely medical intervention should occur if the concern is not related to hospice, while an expanding area of internal bleeding isn't life threatening, it would be a good idea to get a medical evaluation of some kind. No citations are issued as part of this visit, a copy of the Report was read and given to the administrator. The LPA asked for all the hospice narratives for the last 2 months. an exit interview was conducted.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Office

A meeting was held with licensee to discuss a Technical Support Program Engagement Summary (TSP) generated on 01/28/2025. This meeting was held virtually via Teams Meeting. Present at this meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, LPA Noel Wolf Petersen, \ Ombudsman Kathryn Thomas. and Licensee Monica Plowden. At the beginning of the meeting, Licensee confirmed receipt of TSP material from visits on 01/10/25 and 01/28/25. LPM discussed the following topics previously addressed at the TSP Engagement: Personnel / Training In regards to personnel training, licensee has a staff training log already in use and conducted the training's required as part of the informal conference during the month of December 2024. Medication Management The licensee was provided resources, however currently uses Alcame for medication management which allows for audits and quality assurance checks. Therefore, the monthly medication audit and medication room organization guide will not be implemented but may be used as a resource in the future. Record Keeping the licensee reported that there is already a checklist implemented for personnel and resident files. LPM confirmed resources and tools documented in the engagement summary were provided to the licensee. Since links were not provided in the document, LPM will forward them via email. No citations were issued, a copy of this report was delivered via phone and email. .the state’s words, verbatim · CDSS document, Mar 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an required 1 year annual inspection visit. LPA met with Administrator and explained purpose of visit. Census:5 LPA Lund and Administrator toured/inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven- day non-perishable and two- day perishable food supplies. LPA measured the hot water temperature in resident's bathroom at 111.2 degrees Fahrenheit which is within the required range of 105 to 120 degrees. Fire extinguishers last inspected on 1/2/2025. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to clients. LPA reviewed and compared resident medication vs. medication logs. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 11/12/2024. LPA reviewed three resident files and two staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit. Exit interview held with administrator. A copy of report left.the state’s words, verbatim · CDSS document, Feb 21, 2025

Type of visit: Case Management - Other

Unannounced case management visit conducted by Licensing Program Analyst (LPA) Jason who was met by the facility Licensee Monica Plowden. A brief interview was conducted with the facility designated Administrator at this time. Census 5 The purpose of this case management visit was to follow up, with quarterly visits, and inquire about the requirements that were laid out from the office meeting for the informal conference which took place on 12/03/2024. Since the meeting the Licensee Monica Plowden had training. On 12/20/2024 facility staff & Licensee Monica Plowden had training from ARC on RCFE reporting requirements and medication management. On 3/6/2025 Licensee Monica Plowden has a meeting with TSP summary review. The following issues were discussed and reviewed at this time: · Fire Clearance · Reporting Requirements · Personal Rights · Staffing · Medication Policies and Procedures There were no deficiencies observed or cited during today's case management visit. Exit Interviewthe state’s words, verbatim · CDSS document, Feb 21, 2025

Type of visit: Office

Announced Office Informal Meeting was conducted via Teams Meeting by Licensing Program Manager (LPA) Liza King and Licensing Program Analyst (LPA) Charlie Yang who were also joined by the following individuals: 1. Long Term Care Ombudsman Kathryn Thomas 2. Facility Licensee Monica Plowden The purpose of this meeting was to conduct an Informal Meeting and follow up with the facility Licensee Monica Plowden in regard to some recent events and incidents that have taken place at this facility. The following issues were discussed and reviewed at this time: · Fire Clearance · Reporting Requirements · Personal Rights · Staffing · Medication Policies and Procedures The facility Licensee Monica Plowden will complete and submit the following: LIC 500 LIC 200 Facility Sketch (LIC 999) LIC 308 Updated training for all staff (4) in regard to Medications Updated training for all staff (4) in regard to Residents’ Personal Rights Updated training for all staff (4) in regard to Proper Reporting Requirements During the monitoring period, proof of fingerprint clearance will be submitted to the Department prior to hire. During the monitoring period, the facility will maintain a Resident Roster and submit it to the Department monthly. During the monitoring period, all training shall be conducted by an outside provider This facility Licensee was given until the COB of 12/17/2024 to complete and submit all of the above forms and documents into CCL for review. In addition, the Licensee agreed that the following will be put into place: 1. The Administrator will be present at least 40 hours a week during the increased monitoring time period. These hours will be reflected on the updated LIC 500 provided to CCL. A discussion was held about the facility Licensee’s voluntary engagement with Technical Support Program (TSP). Licensee did agree to participate in TSP. CCL will increase monitoring over the next 12 months to provide oversight and guidance as needed. The Department provided the following resources: Technical Support Program Dementia Care Information and Resources No citations issued. A copy of the report was reviewed with the Licensee and provided via email.the state’s words, verbatim · CDSS document, Dec 3, 2024

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 12/02/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person Nordia Heywood. A brief interview was conducted with the facility staff person at this time. This LPA requested that the facility staff person go ahead and contact the facility designated Administrator, Monica Plowden, to inform her that CCL was present at this time. The facility designated Administrator, Monica Plowden, arrived later to this facility while this LPA was conducting this visit. A brief interview was conducted with the facility designated Administrator after her arrival. Current census was 5 residents. The purpose of this visit was to follow up on the deficiencies that were cited from prior complaint and case management visits conducted on 11/14/2024. This visit was to follow up on the Plans of Correction that were due. The following deficiencies were observed and cited on 11/14/2024: Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or: All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. It was learned that all of the citations have not been addressed nor brought back into compliance at this time. The plan of corrections have not been completed and submitted into CCL, for review by this LPA, as requested on the LIC 9099-D and LIC 809-D documents dated on 11/14/2024. All of the above deficiencies will be re-cited and given a new due date for completion, and submission, of the plan of corrections on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Exit Interviewthe state’s words, verbatim · CDSS document, Dec 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g) · Plan of correction due date: Dec 3, 2024

Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or: This facility was found to be deficient as evidenced by the allowance of an individual to be present and employed at this facility prior to obtaining the required criminal clearance. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2024

Plan of correction: This facility representative stated that all facility staff will always be fingerprint cleared and properly associated prior to employment. A statement of correction, along with updated LIC 500, will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87202(a)(2) · Plan of correction due date: Dec 3, 2024

All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons This facility was found to be deficient as evidenced by the allowance of facility residents deemed to be Bedridden to be present receiving care and supervision without the proper issuance of a bedridden fire clearance. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2024

Plan of correction: This facility representative stated that this facility will notify the local fire department about the number of Bedridden residents present in care at this time. In addition, this facility will submit all of the required forms and documents related to care and supervision being provided to residents deemed as Bedridden. A statement of correction, along with all required forms and documents for Bedridden Care, will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(5) · Plan of correction due date: Dec 3, 2024

Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This facility was found to be deficient as based on a records review conducted, 1 out of 6 residents, was found to be diagnosed with dementia and did not have an updated medical assessment on file. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2024

Plan of correction: This facility representative stated that all residents diagnosed with dementia will be reviewed to make sure that all medical assessments have been updated to address any changes in care and supervisory needs. A statement of correction, along with a copy of the updated medical assessment, will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87466 · Plan of correction due date: Dec 3, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This facility was found to be deficient as evidenced by information concluding that the sole facility staff member left the premises so that facility residents were unsupervised for an unknown amount of time. In addition, facility staff did not regularly change and check on the residents to prevent the emergence of pressure injuries and other physical issues. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2024

Plan of correction: The facility designated representative stated that all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of maintaining professionalism to make sure that facility residents' personal rights were always upheld. A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 3, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This facility was found to be deficient as evidenced by information concluding that facility staff members were arguing and engaing in disputes in front of the residents which presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2024

Plan of correction: The facility designated representative stated that all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of maintaining professionalism to make sure that facility residents' personal rights were always upheld. A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Dec 3, 2024

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. This facility was found to be deficient as evidenced by information concluding that the sole facility staff member left the premises so that facility residents were unsupervised for an unknown amount of time. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2024

Plan of correction: The facility designated representative stated that this facility was currently seeking additional staff persons for hire at this time. In addition, all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of proper care and supervision at all times 24 hours/7 days a week. A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 3, 2024

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self- administered medications as needed. This facility was found to be deficient as evidenced by a review of all (6) resident medication administration records revealing that medications were not properly handled, dispensed, or notated which presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Dec 2, 2024

Plan of correction: The facility designated representative stated that all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of proper handling, dispensing, and documentation of the resident medications. A statement of correction, along with documented proof of vendorized medication training, will be completed and submitted into CCL by the due date.

Allegation investigated: Staff did not safeguard resident's personal belongings

Unannounced complaint visit made out to this facility on 11/14/2024 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility live-in caregiver, Nordia Heywood, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Monica Plowden, to inform her that CCL was present at this time. The facility designated Administrator, Monica Plowden, arrived shortly thereafter to this facility while this LPA was conducting this visit. A brief interview was conducted with the facility designated Administrator at this time. Current census was 6 residents. It was learned that there were (3) residents under the care of hospice at this time. This facility is approved to be able to accept and retain up to (4) residents under hospice care at any given time. This LPA requested to review the facility resident files at this time. A review of (6) facility resident files was conducted and noted on the following LIC 858. A brief tour of the facility was conducted as well. Unsubstantiated Based on interviews conducted during the course of this investigation, it was learned that R1 did not have any immediate family or relatives nearby who were present in R1's daily life. Based on a review of the facility forms and documents, it was learned that a Client/Resident Personal Property and Valuables, LIC 621, was completed and signed by all parties dated on 04/01/2022. It was learned that R1 did have a distant relative who resided out of state but was unable to visit and see R1 on a regular basis. It was learned that upon R1's passing, R1's distant relative did relinquish all property and belongings to this facility and facility representatives. This was evidenced by an email that was sent directly to this facility email address, JewellHomeCare@gmail.com, dated on 08/28/2024. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited during today's complaint visit at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 14, 2024 · control 27-AS-20240805094518

Allegation investigated: Facility staff left residents unattended overnight Facility staff are not keeping accurate resident records

Unannounced complaint visit made out to this facility on 11/14/2024 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility live-in caregiver, Nordia Heywood, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Monica Plowden, to inform her that CCL was present at this time. The facility designated Administrator, Monica Plowden, arrived shortly thereafter to this facility while this LPA was conducting this visit. A brief interview was conducted with the facility designated Administrator at this time. Current census was 6 residents. It was learned that there were (3) residents under the care of hospice at this time. This facility is approved to be able to accept and retain up to (4) residents under hospice care at any given time. This LPA requested to review the facility resident files at this time. A review of (6) facility resident files was conducted and noted on the following LIC 858. A brief tour of the facility was conducted as well. Substantiated Based on a review of the facility forms and documents, it was learned that this facility employed a digital version of the Medication Administration Record (MAR) for all facility residents at this time. It was learned that all facility residents had their medications centrally stored and did not have immediate control of their medications at this time. A brief interview was also conducted with the facility designated Administrator, Monica Plowden, in regards to the maintenance, oversight, and auditing of this system. Based on this interview, it was learned that facility staff were responsible to handle, dispense, and notate all of their actions within this program. It was also learned that this program required each individual staff person to log in when it came time for them to dispense the medications as prescribed. It was learned that if a facility resident refused or did not take their prescribed medications in a timely manner, the present facility staff person would use a drop down menu, within the application, to notate that the medications were not given and should include additional notes as to the specific reason. It was observed by this LPA from the monthly medication administration records (MARs), dated from 09/16/2024 to 11/14/2024 for all (6) residents, revealed multiple times and dates where the medications were not property dispensed, not properly documented, and not properly followed up with Notes inputted within this application. Based on interviews conducted during the course of this investigation, it was learned that there wasn't a cohesion within the core group of facility caregivers, which there were (3) main facility staff persons at this time. It was learned that on at least (1) occasion, the oncoming staff came on and discovered that the scheduled staff for the previous shift had left the facility without notification to the oncoming shift or the facility administrative team. It was learned that the facility residents had been left alone, without any facility staff care and supervision, for an unknown amount of time before the oncoming shift finally arrived to take over. It was learned that there were notifications, in the form of phone calls and text messages, that were exchanged with the facility designated Administrator in regards to this incident. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated representative at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 14, 2024 · control 27-AS-20240804123704

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 15, 2024

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. This facility was found to be deficient as evidenced by information concluding that the sole facility staff member left the premises so that facility residents were unsupervised for an unknown amount of time. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: The facility designated representative stated that this facility was currently seeking additional staff persons for hire at this time. In addition, all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of proper care and supervision at all times 24 hours/7 days a week. A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 15, 2024

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self- administered medications as needed. This facility was found to be deficient as evidenced by a review of all (6) resident medication administration records revealing that medications were not properly handled, dispensed, or notated which presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: The facility designated representative stated that all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of proper handling, dispensing, and documentation of the resident medications. A statement of correction, along with documented proof of vendorized medication training, will be completed and submitted into CCL by the due date.

Allegation investigated: Resident sustained pressure injuries while in care. Resident sustained a UTI while in care. Staff left resident soiled for an extended period of time. Staff did not provide adequate supervision to resident in care. Staff engaged in a verbal altercation with another staff in the presence of resident.

Unannounced complaint visit made out to this facility on 11/14/2024 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility live-in caregiver, Nordia Heywood, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Monica Plowden, to inform her that CCL was present at this time. The facility designated Administrator, Monica Plowden, arrived shortly thereafter to this facility while this LPA was conducting this visit. A brief interview was conducted with the facility designated Administrator at this time. Current census was 6 residents. It was learned that there were (3) residents under the care of hospice at this time. This facility is approved to be able to accept and retain up to (4) residents under hospice care at any given time. This LPA requested to review the facility resident files at this time. A review of (6) facility resident files was conducted and noted on the following LIC 858. A brief tour of the facility was conducted as well. Substantiated Based on interviews conducted during the course of this investigation, it was learned that there wasn't a cohesion within the core group of facility caregivers, which there were (3) main facility staff persons at this time. It was learned that on at least (1) occasion, the oncoming staff came on and discovered that the scheduled staff for the previous shift had left the facility without notification to the oncoming shift or the facility administrative team. It was learned that the facility residents had been left alone, without any facility staff care and supervision, for an unknown amount of time before the oncoming shift finally arrived to take over. It was learned that there were notifications, in the form of phone calls and text messages, that were exchanged with the facility designated Administrator in regards to this incident. Based on interviews conducted during the course of this investigation, it was learned that there was evidence to support that facility residents were left in soiled depends for extended periods of time leading to the development of pressure injuries and other health related injuries. It was learned that these other possible injuries led facility residents to be diagnosed with Urinary Tract Infection (UTI) as well. It was learned that these types of incidents would lead facility staff persons to have several verbal exchanges, which were highly unprofessional, to take place in front of the residents at times. It was learned that facility staff persons would raise their voices, yell, and even use profanity as well while all in the presence of the facility residents. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated representative at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 14, 2024 · control 27-AS-20240805084146

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Nov 15, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This facility was found to be deficient as evidenced by information concluding that the sole facility staff member left the premises so that facility residents were unsupervised for an unknown amount of time. In addition, facility staff did not regularly change and check on the residents to prevent the emergence of pressure injuries and other physical issues. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: The facility designated representative stated that all facility staff will be trained, for no less than (2) hours in duration, from a third party vendor on the topic of proper care and supervision at all times 24 hours/7 days a week, dealing with and preventing pressure injuries, and dealing with and preventing UTIs. A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 15, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This facility was found to be deficient as evidenced by information concluding that facility staff members were arguing and engaing in disputes in front of the residents which presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: The facility designated representative stated that all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of maintaining professionalism to make sure that facility residents' personal rights were always upheld. A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date.

Type of visit: Case Management - Deficiencies

Unannounced case management visit made out to this facility on 11/14/2024 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility live-in caregiver, Nordia Heywood, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Monica Plowden, to inform her that CCL was present at this time. The facility designated Administrator, Monica Plowden, arrived shortly thereafter to this facility while this LPA was conducting this visit. A brief interview was conducted with the facility designated Administrator at this time. Current census was 6 residents. It was learned that there were (3) residents under the care of hospice at this time. This facility is approved to be able to accept and retain up to (4) residents under hospice care at any given time. This LPA requested to review the facility resident files at this time. A review of (6) facility resident files was conducted and noted on the following LIC 858. A brief tour of the facility was conducted as well. The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. The following civil penalty was assessed and levied in the amount of $500 on the following LIC 421BG. The following civil penalty was assessed and levied in the amount of $500 on the following LIC 421IM. Appeal rights were printed and a copy was left with the facility designated representative at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Nov 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g) · Plan of correction due date: Nov 15, 2024

Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or: This facility was found to be deficient as evidenced by the allowance of an individual to be present and employed at this facility prior to obtaining the required criminal clearance. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: This facility representative stated that all facility staff will always be fingerprint cleared and properly associated prior to employment. A statement of correction, along with updated LIC 500, will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87202(a)(2) · Plan of correction due date: Nov 15, 2024

All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons This facility was found to be deficient as evidenced by the allowance of facility residents deemed to be Bedridden to be present receiving care and supervision without the proper issuance of a bedridden fire clearance. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: This facility representative stated that this facility will notify the local fire department about the number of Bedridden residents present in care at this time. In addition, this facility will submit all of the required forms and documents related to care and supervision being provided to residents deemed as Bedridden. A statement of correction, along with all required forms and documents for Bedridden Care, will be completed and submitted into CCL by the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(5) · Plan of correction due date: Nov 15, 2024

Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This facility was found to be deficient as based on a records review conducted, 1 out of 6 residents, was found to be diagnosed with dementia and did not have an updated medical assessment on file. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: This facility representative stated that all residents diagnosed with dementia will be reviewed to make sure that all medical assessments have been updated to address any changes in care and supervisory needs. A statement of correction, along with a copy of the updated medical assessment, will be completed and submitted into CCL by the due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with Administrator and explained purpose of visit. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water temperature in resident's bathroom at 112.8 degrees Fahrenheit which is within the required range of 105 to 120 degrees. Fire extinguishers last inspected on 1/10/2024. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to clients. LPA reviewed and compared resident medication vs. medication logs. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 10/24/2023. LPA reviewed three resident files and five staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. LPA requested the following updated documents to be submitted via email to community care licensing by February 12, 2024: LIC 308, LIC 500 - Personnel Report, Copy of Liability Insurance, and Copy of Administrator Certificate. ruth.wallace@dss.ca.gov Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit. Exit interview held with administrator. A copy of report and LIC 811 (Confidential Names) were left at facility.the state’s words, verbatim · CDSS document, Feb 4, 2024