Joy Senior Center

Allegation investigated: Resident sustained an unexplained fracture while in care

On 04/15/25 at 2PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with staff (S1) and spoke with administrator (ADM) on the phone who authorized S1 to act on his behalf and sign the reports. LPA explained the purpose of the visit with staff and delivered investigation findings. During investigation, the department obtained the following documents from administrator – R1’s admission agreement, physician's report, Needs/Services plan, appraisals, incident reports, hospital visit discharge reports, visitor logs (Mar, Apr, May 2024) Level of care notes & ADL schedules. Health & safety check conducted see LIC 809 dated 05/23/24. Continued on next page, LIC 9099-C Substantiated Allegation: Resident sustained an unexplained fracture while in care Investigation Finding: Substantiated During investigation, the department conducted interviews of residents (R1, R2, R3), facility staff (ED, S1, S2) & R1’s responsible party (POA) and reviewed resident (R1) documents. Review of R1’s records showed she was first admitted at the facility on 03/08/24 and resided at the facility for a couple of months. R1 was assessed as having dementia, ambulatory with a walker, needs assistance transferring in & out of bed, dressing and a high risk for falls. On 04/14/24, R1 was diagnosed with a displaced fracture of the left wrist. R1 stated that she hurt her left wrist at the facility when she fell out of bed. Staff (S1, S2) stated R1 had three falls at the facility (2 unwitnessed falls at night and one unwitnessed fall in the daytime) while at the facility. S2 stated that he found R1 on the floor on 2 separate occasions. R1 did not complain of any pain and helped her get back to bed. S2 confirmed that there were no fall precautions in place after R1’s repeated falls and that her repeated falls were not documented. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that resident sustained an unexplained fracture while in care was found to be substantiated. Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining unexplained injuries while in care. Additional civil penalty determination is pending relating to resident’s serious bodily injury. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Resident sustained unexplained injuries while in care Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of residents (R1, R2, R3), facility staff (ED, S1, S2, S3) & R1’s responsible party (POA) and reviewed resident (R1) documents. S1 and R2 denied hitting R1. Staff (ED, S1, S2) confirmed that R1 sustained unexplained injuries while at the facility. S3 stated that on 05/21/24 at around 0710 AM she observed R1’s face was bruised with her lip slightly bleeding. S3 observed R1 sitting in her chair instead of sleeping on her bed while R1’s roommate (R2) was sleeping in R1’s bed instead. S3 stated that she asked R1 what happened and R1 stated that R2 hit her. Staff notified R1’s POA about the incident. Later at breakfast, S3 stated that R1 changed her story and said that staff (S1) hit her instead of R2. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident sustained unexplained injuries while in care is unsubstantiated. Allegation: Staff did not ensure resident’s diapering needs are being met in a timely manner Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s bowel movement/pee records dated 03/10/24 until 05/28/24 showed staff assisted R1 with her toileting needs and changed her diapers frequently (3 to 6 times per day). Staff (ED, S1, S2) stated that they showered, changed residents’ diapers/clothes based on their preferred daily and weekly personal hygiene schedules which they recorded each month. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure resident’s diapering needs are being met in a timely manner is unsubstantiated. Continued on next page, LIC 9099-C pg3 Allegation: Staff does not ensure resident’s showering needs are being met Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s monthly shower schedules dated 03/10/24 until 05/28/24 showed that staff gave R1 showers according to family schedules on 03/10, 03/11, 03/15, 03/16, 03/19, 03/23, 03/26, 03/27, 03/31, 04/01, 04/09, 04/09, 04/14, 04/23, 04/24, 04/29 and every Monday, Wednesday and Friday for the whole month of May 2024. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure resident’s showering needs are being met is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 15-AS-20240520131013

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 18, 2025

Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs… This requirement was not met as evidenced by staff failing to provide adequate care & supervision which posed an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: By POC due date, administrator agreed to complete and submit in-service staff retraining certifications by an approved CCL vendor on personal rights of residents in compliance with Section 87468.2 (a)(4). Immediate civil penalty of $500 assessed during visit for serious bodily injury. Additional civil penalty determination pending relating to serious bodily injury.

Type of visit: Case Management - Other

On 5/31/2024 at 09:30AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and T. Syess- Gibson conducted an unannounced Case Management visit to follow-up on the accusation document that was provided to the facility. LPA met with Rose Constantino, Caregiver and explained the purpose of the visit. Licensee Gurpreet "Bobby" Matharu, was called and agreed to have Rose sign off on the report. LPA toured facility with Caregiver, Rose Constantino and observed the facility posted written notice regarding the accusation. LPA confirm that all fourteen (14) residents have received written. During visit LPA obtained the notice that was posted in the facility and the notice that was sent to the residents or their responsible party. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 31, 2024

Type of visit: Case Management - Deficiencies

On 5/31/2024 at 09:30AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and T. Syess- Gibson were at the facility for a Case Management LPAs observed that the back emergency exit pathway was blocked by two bedframes. The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, May 31, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Jun 3, 2024

All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above by having bedframes blocking the emergency exit passageway from the back door which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: The facility agrees to remove the bedframes from the passageway. Proof of correction will be sent to CCLD by POC date.

Allegation investigated: Staff inappropriately touched resident

On 5/28/2024 at 9:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to deliver findings on the allegation above. The LPA informed Caregiver Rose Constantino of the purpose of the visit. The Department's investigation included, but was not limited to, a physical inspection of the facility; record reviews of facility, staff, resident documentation, and Brentwood Police Department (BPD) reports; and interviews of the Reporting Party (RP), resident R1, 3 other facility residents, accused staff member S1, and 4 other staff members. Continues on LIC9099-C . . . Unsubstantiated . . . Continued from LIC9099 The complaint alleges that staff inappropriately touched resident R1. The BPD investigated the matter and was unable to find any witnesses or physical evidence to prove that abuse occurred. Therefore, the BPD inspection was closed with a finding of unfounded. The Department’s interviews of the 4 staff members who were not accused of inappropriately touching R1 revealed significant inconsistencies in R1’s statements to them about the alleged inappropriate touch by S1. Physical inspection of the facility, reviews of records, and interviews of 3 of the other residents revealed no witnesses or physical evidence to show that R1 had been inappropriately touched by staff member S1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 28, 2024 · control 15-AS-20230719141352

Type of visit: Case Management - Health Checks

On 05/23/24 at 01:30PM, Licensing Program Analysts (LPAs) D Panlilio and T Syess- Gibson conducted an unannounced Health and Safety check due to the department receiving a priority 1 complaint. During the health and safety check, LPA observed a total of 7 staff members and 15 residents at the facility. LPA toured facility with administrator (ADM), including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 23, 2024

Type of visit: Required - 1 Year

On 03/29/2024 at 12:05PM, Licensing Program Analysts LPAs T.Syess-Gibson and L. Hall conducted an unannounced Annual 1-year required inspection. Caregiver Meledel Sumaylo contacted the Administrator by phone. LPAs toured the facility with caregiver Inoke Moa. Administrator, Gurpreet Matharu arrived at 2:00PM. The administrator currently holds a certificate (#6041833740) that expires on 08/15/2024. The facility’s fire clearance was approved for twelve (12) Non ambulatory and six (6) Bedridden residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of eleven (11) total bedrooms which Ten (10) bedrooms are occupied by the residents. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.5 degrees Fahrenheit. Night lights are maintained in hallways and passages to nonprivate bathrooms. Residents’ bathrooms are equipped with grab bars no non slip mats observed. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/08/2023. Emergency Disaster Plan was last posted on 11/18/2023. First aid kit was observed to be complete. Fire drill was last conducted on 11/03/2023. Continued on LIC809C. Continued from LIC809 The following deficiencies were observed: At 12:30 PM LPAs observed all three (3) of the shared bathrooms did not have non skid mats. At 12:32PM LPAs observed four (4) walkers, two(2) Wheel Chairs and one(1) Hoyer Lift located in the hallway blocking passageway. At 12:36PM LPAs observed beds did not have mattress pads. At 12:45PM LPAs observed there wasn't a Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. At 12:50PM LPAs observed refrigerator unsanitary. At 12:55PM LPAs observed garbage inside of a grocery store basket on the side of the facility . At 12:56 PM LPAs observed wooden planks from broken fence on ground obstructing walk path. At 12:58PM LPAs observed Washer and Dryer on side of the facility blocking room number 2 exit. At 2:25PM LPAs observed unlocked medicine cabinet containing resident medication. At 4:45PM LPAs observed Medicine Administration Record was inaccurate. Six (6) residents records were reviewed, current, and complete. Six (6) staff records were reviewed. LPAs also reviewed a sample of medication. Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 04/05/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report Continued on LIC809C. Continued from LIC809C LIC 610E Emergency Disaster Plan (last page) Residents roster Updated facility sketch Liability Insurance Deficiencies cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy the appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 29, 2024