Joe-Sephine Residential Care Fac. for the Elderly

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced one (1) year Required visit at this facility. LPA was greeted by Administrator Josephine Sanoy and informed of the purpose of the visit. LPA observed two (2) residents watching TV the living room and one (1) was eating breakfast at the dining table A tour of the physical plant was conducted with the Administrator at 9:45 AM. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for three (3) non-ambulatory, one bedridden, and a hospice waiver for one resident. Infection control: The facility is following current infection control recommendations. The main door is the only entrance being utilized at this facility. The required poster are posted at the main door. Screening area is located immediately after entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. Food Inspection: LPA conducted a tour of the kitchen and observed that there are sufficient stock of both perishable and non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. The medication cabinet was also observed to be locked. Cleaning supplies and chemicals were observed to be locked in the storage room. (continued from LIC 809) Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational. There is a fire extinguisher located in the living room. The Fire extinguisher was observed to be full and last serviced 6/24/23. Garage/Laundry: LPA observed the garage to be attached to the facility and is currently being used for storage. LPA observed a refrigerator and deep freezer in the garage. The Laundry room is located in the garage. All chemicals/hazardous items were observed to be locked in a cabinet. Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. All alarms on the exit doors are functional. Bathrooms: LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested and measured at 118.1°F and within the range. Physical environment: LPA observed a covered shaded area for residents. No bodies of water on the premises. LPA observed all tools in a locked gated area. Staff and residents records were checked. Staff present has criminal record clearances and associated to this facility. Staff records appear to be complete and current. Client records were also reviewed and appeared to be complete and current. Disaster drill was last conducted on 09/14/23. Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 15, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Shira Stamps arrived at the facility for an unannounced one (1) year Required visit. LPA arrived at 10:00 am, and was greeted by Licensee Josephine, LPA informed the Licensee of the purpose of the visit. LPA observed two residents watching TV the living room. A tour of the physical plant was conducted with the Licensee at 10:10 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for three (3) non-ambulatory, one bedridden, and a hospice wavier for one. The facility currently has one (1) ambulatory and two (2) non- ambulatory residents. Infection control: LPA reviewed the mitigation plan approved on 3/20/21. The Licensee emailed the infection control plan on 6/16/22. The LPA still needs to review for approval. The facility is following current infection control recommendations. Upon arrival LPA was screened by the Licensee and asked all infection control questions. LPA was asked to sign-in and sanitize hands. Food Inspection LPA conducted a tour of the kitchen around 10:10 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. The medication cabinet was also observed to be locked. Cleaning supplies and chemicals were observed to be locked under the kitchen sink. CONTINUED... Living and dining At 10:15 am, LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:15 am. There one (1) fire extinguisher located in the living room. The Fire extinguisher was observed to be full and last serviced 6/10/22. Garage/Laundry At 10:23 am, LPA observed the garage to be attached to the facility and is currently being used for storage. LPA observed a refrigerator and deep freezer in the garage. The Laundry room is located in the garage. All chemicals/hazardous items were observed to be locked in a cabinet. Resident Rooms LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. All alarms on the exit doors are functional. Bathrooms LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 10:29 am and measured within regulation at 116.3 degrees F. Physical environment LPA toured the outside area of the facility at 10:22 am. LPA observed a covered shaded area for residents. No bodies of water on the premises. LPA observed all tools in a locked gated area. Administrative: Annual fee is current. An exit interview was conducted, and a copy of this report was given to the Licensee.the state’s words, verbatim · CDSS document, Jun 21, 2022

Allegation investigated: Facility is not following COVID-19 guidelines. Facility staff are not wearing masks. Residents are not able to receive visitors at the facility. Residents have access to chemicals at the facility.

At 12:55 pm, Licensing Program Analysts (LPAs) Shira Stamps and Joscelyn Martinez conducted a subsequent complaint visit regarding the complaint allegations listed above. LPA met with the facility Administrator Joesphine Sanoy. Entrance interview conducted, and physical plant tour conducted. This report is being issued based on new information received from a reliable source regarding the following allegations. Facility is not following COVID-19 guidelines. Based on a reliable source the facility is not following COVID-19 guidelines, and are not screening visitors. Therefore, after further investigation the allegation, “Facility is not following COVID-19 guidelines,” is deemed substantiated. Substantiated Allegation: Residents are not able to receive visitors at the facility. Based on observation from a reliable source, the facility had a no visitors sign posted. Therefore, upon further investigation the allegation, “ Residents are not able to receive visitors at the facility,” is deemed substantiated. Allegation: Residents have access to chemicals at the facility. Based on additional information received from a reliable source, the Administrator had chemicals accessible to residents. The Administrator stated during a visit from the Ombudsman the Administrator left the door unlocked to the closet with the chemicals to answer the door. Therefore, upon further investigation the allegation, “Residents have access to chemicals at the facility, “ is deemed substantiated. Exit interview conducted, citations issued, and copy of report delivered. Facility staff are not wearing masks. Based on observation from a reliable source, the facility staff was not wearing masks. Therefore, upon further investigation the allegation, “Facility staff are not wearing masks,” is deemed substantiated. Allegation: Residents are not able to receive visitors at the facility. Based on observation from a reliable source, the facility had a no visitors sign posted. Therefore, upon further investigation the allegation, “ Residents are not able to receive visitors at the facility,” is deemed substantiated. Allegation: Residents have access to chemicals at the facility. Based on additional information received from a reliable source, the Administrator had chemicals accessible to residents. Therefore, upon further investigation the allegation, “Residents have access to chemicals at the facility, “ is deemed substantiated. Exit interview conducted, citations issued, and copy of report delivered.the state’s words, verbatim · CDSS document, Feb 14, 2022 · control 31-AS-20211214120924

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(2) · Plan of correction due date: Feb 21, 2022

87468(a)(2) Personal Rights. (a) Each resident shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Bases on observations from a reliable source, the licensee did not ensure the personal rights of persons in care to a safe, healthy, and comfortable home and engaged in conduct inimical to the health, welfare, and safety of persons in care, in that facility staff did not wear a mask, and did not follow COVID-19 guidelines by screening visitors.the state’s words, verbatim · CDSS document, Feb 14, 2022

Plan of correction: The Licensee agrees to provide current training to all staff members on the subject: the approved mitigation plan. Documentation shall be submitted to LPA by POC date, via email or fax.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.313 · Plan of correction due date: Feb 21, 2022

1569.313(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by: Based on observations from a reliable source, the licensee did not permit residents to have visitors in that the facility had no visitors signs posted.the state’s words, verbatim · CDSS document, Feb 14, 2022

Plan of correction: The Licensee has completed the plan of action and has previously removed the no visitor’s sign.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Feb 21, 2022

87309(a) Storage Space Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidence by: Based on observations from a reliable source, the licensee had cleaning solutions accessible to residents in care.the state’s words, verbatim · CDSS document, Feb 14, 2022

Plan of correction: The Licensee has agreed to provide current training to all staff working in the facility, on the subjects of securing toxins and chemicals. Documentation shall be submitted to LPA by POC date, via email or fax.

Allegation investigated: Facility is not following COVID-19 guidelines. Facility staff are not wearing masks. Residents are not able to receive visitors at the facility. Residents have access to chemicals at the facility.

At 10:02am Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above for a subsequent complaint visit. Entrance interview conducted. At approximately 10:05 am, LPA conducted a physical plant walk through, and LPA did not observe any immediate health and safety issues during this visit. Allegation: Facility is not following COVID-19 guidelines. Upon arrival to the facility during the initial complaint visit, LPA’s temperature was taken, COVID screening questions were asked, sanitizer was available, and LPA was asked to sign in. On the subsequent visit the same procedure was completed by facility staff. LPA suggested for the Administrator to record the temperatures of guests in the log in book. Therefore, after observations the allegation, “Facility is not following COVID-19 guidelines,” is deemed unsubstantiated. Continued.... Unsubstantiated Allegation: Facility staff are not wearing masks. During the initial complaint visit, LPA observed a facility staff answer the door without a mask on. During the physical plant walk through the staff member put on a mask. All other facility staff was observed to have a mask on. During the subsequent complaint visit, all facility staff was observed wearing a mask. Based upon observations the allegation, “Facility staff are not wearing masks,” is deemed unsubstantiated. Allegation: Residents are not able to receive visitors at the facility. Interviews with two (2) out of two (2) staff members indicated that residents can have visitors in the facility. One (1) out of two (2) staff members stated only one (1) resident has family to visit, but they prefer to visit virtually. One (1) out of two (2) residents indicated that they do not have visitors and are unsure why. One (1) out of two (2) residents indicated they do not have visitors because they do not have family that live in the area. LPA reviewed the guest log in book and found multiple guests that have signed in over the span of five (5) months. LPA observed signs on the door stating visitors are welcome. Therefore, after review of the information and interviews conducted the allegation, “Residents are not able to receive visitors at the facility,” is deemed unsubstantiated. Allegation: Residents have access to chemicals at the facility. During the initial physical plant walk through, chemicals were found in the locked garage. LPA informed the Administrator to place the chemicals in a locked cabinet in the locked garage for extra security. No chemicals were found accessible to the residents. Therefore, after observations the allegation, “Residents have access to chemicals at the facility,” is deemed unsubstantiated. Exit interview conducted. Report delivered.the state’s words, verbatim · CDSS document, Dec 27, 2021 · control 31-AS-20211214120924