Katie's House

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required inspection and met with caregiver Lorenzo Tii who allowed the entry of the facility and explained the reason of the visit. Shortly after, the house manager Nicholas Baez arrived and assisted with the visit. The facility is licensed to serve adults age 60 and above. Fire clearance for four (4) ambulatory and two (2) non-ambulatory. The facility is licensed as a 4C home vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Operational Requirements, Physical Plant/Environmental Safety, Staffing, Personal Records-Training, Resident Rights/Information, Resident Records/Incident Reports, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness and Resident with Special Health Needs. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is still in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements: A fire clearance for four (4) ambulatory and two (2) non-ambulatory and currently three (3) residents are ambulatory and one (1) resident is non-ambulatory. The facility is vendored by San Gabriel Pomona Regional Center, therefore no dementia waiver and hospice waiver in place at the present time. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. A Surety Bond is in place. The facility handles resident monies. 3. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: Living room, kitchen, dining area, four clients bedrooms, two clients bathrooms and attached garage. Exit doors are free of any obstruction and there are no pools or large bodies of water. (See Next Page) Bedroom#1 has two beds, two drawers, required furniture and bedding and sufficient lighting and closet space. Bedroom#2, #3 and #4 has one bed, one drawer, one chair, night stand, required bedding and furniture and sufficient lighting and closet space. The two clients' bathrooms are clean and sanitary. The water in the Bathroom#1 sink was not drained. The bathrooms also have the required grab bar and non-skid mat, The hot water in both bathrooms were tested between 110.4 and 111.2 degrees F. which are within the Title 22 regulation. All the sharp knives and utensils are stored and locked in the medication cabinet near the living room. All the appliances in the kitchen and living room are working probably. All the chemicals and cleaning supplies are stored and locked in the cabinet in the garage. LPA also inspected the smoke detectors and they are all interconnected and also inspected the carbon monoxide detectors and its working well. The facility has a land-line telephone system for residents to access. 4. Staffing: The facility has sufficient staffing in the facility. Also all staff has an updated CPR and First Aid Training. The night shift staff also has an planned emergency procedure training. 5. Personnel Records-Training: The staff files are stored in the medication cabinet. All staff are over 18 years old and criminal background clearance and associated with the facility. The administrator is Carrie Dobrenen and her certificate is expired on 11/15/23. The administrator has all the required training. All the staff also has completed the 10 hours of initial training and ongoing training each year. 6. Resident Records-Incident Reports: The residents files are stored in the medication cabinet. LPA inspected four (4) resident files: Each resident files has the required documents including face sheet, admission agreement, updated physician report and updated Individual Program Plan (IPP) but 3 of the residents have no preplacement appraisal information in resident's files. 7. Resident-Right Information: RCFE complaint poster (Long Term Care Ombudsman and Community Care Licensing) and Personal rights were observed posted but no nondiscrimation notice. The Incident report folder was reviewed. 8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Also the facility has different recreational materials for residents to utilize. (See Next Page) 9. Food Service: The facility has sufficient supply of 2 days non-perishable and 7 days non-perishable food supply and emergency food supplies. All the food are stored probably in the facility. No residents in the facility are currently on modified diet but facility staff will chop the food into small pieces to prevent choking. 10. Incidental Medical and Dental: Facility will provide transportation for residents' medical and dental appointment. All the medication in the facility are centrally stored and locked in the medication cabinet. LPA inspected four (4) residents' medication and all residents' medication are seemed accurate and updated. And all resident receive 30 days supply of medication. 11.Disaster Preparedness: The updated emergency disaster plan was updated (LIC610E) and the last emergency drill was conducted on 8/21/23. The facility also has two alternative temporary shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training. 12.Residents with Special Health Needs: Currently no residents are on hospice or home health, also no residents with restricted health condition or prohibited health condition or postural support. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Nelida Arlante. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Sep 14, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Nicholas Baez (House Manager) and explained the purpose of the visit. THE FACILITY IS LICENSED TO SERVE ADULTS AGE 60 AND ABOVE. FIRE CLEARED FOR FOUR AMBULATORY AND TWO NON-AMBULATORY. ROOMS #2 & 3 ARE AMBULATORY ONLY. ROOM #1 IS NON-AMBULATORY. A tour of the single story facility contains: Living room, kitchen/dining room, 4 resident bedrooms, 2 bathrooms and an attached garage/laundry area. During today’s visit, LPA observed the following: Sufficient lighting, non-skid mats in all bathrooms, hot water temperature measured between 105 degree F to 120 degree F in the bathroom, all bathing facilities in operable condition containing grab bars, no bodies of water on the premises, no firearms on the premises, toxins stored inaccessible to residents. Smoke detector and carbon monoxide detector are operable. All outdoor passage ways are free of obstruction. Facility maintains a comfortable temperature for the residents. Facility has an approved fire clearance for non-ambulatory persons. There is sufficient staff, the administrator is on the premises during normal business hours. Staff has criminal record clearance, staff have sufficient hours of training and current first aid/CPR training. Facility has sufficient space to accommodate indoor and outdoor activities, furnished areas is provided for relaxation of residents. All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature, toxins are stored separate from foods, kitchen is kept clean. All centrally stored medications is labeled and maintained in compliance with state and federal law. No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided to Nicholas Baez.the state’s words, verbatim · CDSS document, May 9, 2022

Allegation investigated: Facility staff speak inappropriately to residents Facility staff did not assist residents with hygiene needs Facility staff did not assist residents with making doctor appointment Facility staff do not ensure that residents have an adequate amount of clothing Facility staff are not ensuring that there is an adequate amount of food in the facility Facility is not clean Facility staff restrained resident

Licensing Program Analysts (LPAs) Christine Wong and Alberto Lopez conducted a complaint visit to investigate the above allegations; LPAs met with staff Andrew Baez and explained the reason for the visit. Shortly after, the house manager Nick Baez and Administraor Carrie Dobrenen arrived the facility and assisted with the visit. The investigation consisted of the following: LPAs interviewed five (5) residents (R1- R5). LPAs also interviewed five staff (S1-S5) and reviewed all residents' file and toured the facility. The investigation revelaed of the following: Allegation#1 "Facility staff speak inappropriately to residents" LPA interviewed all residents and all reported staff never speak inappropriately or yelled at them. All the staff are nice. LPA interviewed staff and all denied the allegation. The staff stated they would never do that to residents and they never observed any staff speak inappropriately to residents (See LIC 9099C for continuation) Unsubstantiated Allegation#2 "Facility staff did not assist residents with hygiene needs" LPA interviewed 5 residents and they stated that they assisted them with showering and all other hygiene needs. All staff take good care of them. LPAs also observed the resident dress appropriate with clean and nice clothes , hair got brushed, no bad odor and all nails got trimmed. All residents in the facility are able to maintain cleanliness and good hygiene. Allegation#3 "Facility staff did not assist residents with making doctor appointment" LPA interviewed residents and the staff are always on top of it. LPA interviewed staff and they reported residents usually sees their doctor regularly. Staff also stated that if something emergency and they will send resident to urgent care or emergency room immediately. LPA also reviewed residents' file and they all have an updated physician report. They all had a lab test between February and April, 2021. They also had monthly visit with psychiatrist through video chat. In addition, all residents also had a recent dental appointment on May, 2021. Allegation#4 " Facility staff do not ensure that residents have an adequate amount of clothing. LPA interviewed all residents and they reported that they all have enough clothes. LPAs also observed all five residents closet and they all have sufficient amount of clothing which included different weather clothing. Staff also reported they will assist residents with shopping during this pandemic. Allegation#5 "Facility staff are not ensuring that there is an adequate amount of food in the facility." LPA interviewed all residents and all reported that they do have well enough amount of food for each meal. Staff also denied the allegation and reported they always provide variety of food option to resident. They would provide substitute choice if resident does not like the food on the menu. LPA also toured the kitchen, and observed the refrigerator and storage for food supply and they have the supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Allegation#6 "Facility is not clean." LPA interviewed resident and reported the facility is always clean. LPAs toured the facility and observed the facility is clean, with no smell and all the appliances looks working and functioning properly. While LPA observed residents' nursing recommendation and recommended R1 with special diet which include low fat diet, NAS (No Added Salt) due to high cholosterol, R2 with low sodium, healthy and 1800 calories diet. R3 with low sodium, 1800 calories diet due to hypertension. R4 with low sodium , healthy and 1800 calories diet due to hypertension. On today's lunch, the bologna contains a lot of sodium and fat as well as some preservatives. Based on the record review and LPA's observation, therefore, the allegation is substantiated. The following deficiency was cited per California Code of Regulations, Title 22. Refer to 9099D. Exit interview conducted. A copy of the report and appeal rights were discussed and provided to the House Manager Nick Baze Allegation#7 "Facility staff restrained resident." LPA interviewed residents and all denied staff restrained them. LPA interviewed staff and denied the allegation and reported they never tired resident with blanket while the resident on the wheelchair. LPA reviewed R5's file and observed R5's doctor recently prescribed the gait belt and used around the wheelchair for safety issues but staff stated that they are only planning to use the gait belt for transporting in an out from the car to the doctor appointment. Staff did not restrain resident. Based on the interviews were conducted and LPA's observation, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and the copy of the report and appeal right was provided to Administrator-Carrie Dorbrenen.the state’s words, verbatim · CDSS document, Jul 21, 2021 · control 28-AS-20210714152940

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Aug 21, 2021

87555 General Food Service Requirements (a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents The requirement is not met as evidenced by Based on the record review and LPAs observation, LPA observed today's lunch with bologna sandwiches with shadded carrot and string cheese but R1-R4 are recommended to have low sodium diet, healthy diet and 1800 calorie and speical diet for R1 due to their medical codnition which pose a potential risck to resident in carethe state’s words, verbatim · CDSS document, Jul 21, 2021

Plan of correction: Facility/Licensee will provide an updated special meal plan for R1 and other residents with low sodium diet meal plan for residents and send to LPA by POC due date.