Laguna Star Home

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on an incident report. LPA Moleski spoke with administrator Romaine Felix over the phone and explained the purpose of the visit. LPA Moleski received an illegible incident report on July 13, 2023. Felix said she had scanned and sent the incident report to LPA Moleski. LPA Moleski did not receive a scan of this incident report. LPA Moleski reviewed a copy of this incident report during this visit. The report described a resident (R1) being sent to the hospital for pneumonia and a urinary tract infection on July 9, 2023. LPA Moleski reviewed R1's file. No deficiencies were cited during this visit. Felix said staff member Leonora Cosme could sign this report in her absence. An exit interview was held and a copy of this report was left with Cosme.the state’s words, verbatim · CDSS document, Aug 3, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with administrator Romaine Felix and explained the purpose of the visit. Felix's administrator certificate number is 6015606740 and it expires on 4/5/24. LPA Moleski reviewed three resident files (R1-R3) and three staff files (S1-S3). LPA Moleski toured the facility with Felix and inspected common areas, kitchens, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 69 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature was tested and measured 107 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day perishable supply of food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed two staff members (S2-S3) and one resident (R4). No deficiencies were cited during this vist. An exit interview was conducted and a copy of this report was left with Felix.the state’s words, verbatim · CDSS document, Jun 26, 2023

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA Valerio was met by Administrator June Angeles, and explained the purpose of the visit. Staff confirmed there are zero residents or staff that have displayed any signs or symptoms of COVID-19 in the last 10 days. LPA toured the facility to ensure compliance with Title 22 regulations. LPA observed resident bedrooms, resident bathrooms, staff bedroom, and staff bathroom. Resident rooms were observed to have all necessary furniture and furnishings. Emergency exits were free from obstructions. Medication cabinets were locked. No health or safety concerns were observed. LPA observed training files for staff. Staff certificates from 2022 were observed to be in the file. LPA requested the following documentation: LIC 500, LIC 308, Daily Activity Schedule, Daily Showering Schedule, Completed Training from MD Quinley, Shout out Loud, and Career Smart, Proof of facility vehicle, updated liability insurance Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies were observed. Exit Interview was conducted with Administrator June Angeles, and a copy of report was left at facility.the state’s words, verbatim · CDSS document, Aug 9, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met Administrator and explained purpose of today's visit. Current census was 6 residents. LPA and Administrator toured facility. Common areas were toured. Living area, recreation area, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were in good repair and able to meet the needs of the residents at this time. resident bedrooms and restrooms was conducted. Resident bedroom furniture and furnishings were observed to be in good repair and able to meet the needs of the residents at this time. Grab bars and non-skid mats/surfaces were observed to be present and in good repair at this time. Kitchen area was toured. Food supply was reviewed for adequate 2 day perishable and 7 day nonperishable food quantities. Cabinets and drawers were opened and the contents were reviewed to make sure that there was an ample supply of cups, dishes, and all other items able to meet the needs of the residents at this time. Exterior grounds of this facility was toured. A review was conducted in regards to the facility perimeter fence and side gates. First aid kit was reviewed and observed to contain all required components at this time. Fire extinguishers annual inspection by the local fire extinguisher company are in compliance at this time. Hot water temperatures were measured in kitchen sink at 110.0 F which meets the requirement of allowed range of 105-120 degrees. Laundry room was toured. It was observed that laundry detergents, cleaners, and cleaning supplies were locked and made inaccessible to the residents at this time. Garage area was toured. Continue on 809-C Continued from 809 - Page 2 A review of the medications for the residents, stored in a kitchen cabinet, was conducted. A review of the facility Medication Administration Record, dispensing log, and Control Book for narcotics was conducted. Linen closet was reviewed and observed to contain a sufficient supply of sheets, blankets, and covers in order to properly meet the needs of the residents at this time. A review of (3) facility personnel records was conducted and staff have current first aid certificates. A review of (2) facility resident records was conducted and all required documents are in files per Community Care Licensing Regulations. No deficiencies Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8 on today's date. Exit Interview was conducted with Administrator. Copies of reports and appeal rights were left at facility.the state’s words, verbatim · CDSS document, Jul 25, 2022

Type of visit: Case Management - Other

On 12-30-21 LPA Hubbard conducted a unannounced Case management visit. LPA met with facility Administrator Romaine Felix to discuss the purpose of the visit. LPA Hubbard asked if any residents or staff were positive. Administrative stated that there is one presumptive positive who will be retesting. Administrator has notified CCL via Fax and email. LPA toured the physical plant of the facility and reviewed MAR for all persons in care. The MAR for all 6 residents is up to date and in compliance with CCL regulations. LPA observed staff and residents wearing mask and social distancing. On 12-9-2021 Alta Regional center conducted a case management visit placing the facility on Sanctions due to medication errors. The regional found substantial inadequacies which pose a danger to residents health and safety or conditions related to consumer services as defined in Title 17, 56054. On 12-1-2021, ACRC Liaison Support Coordinator (LSC) Jazmin Kung Gunion was present a the Laguna Star Home to conduct an IP meeting. Care Home representative were Assistant Administrator Romaine Felix and staff Anita Gerobin. Medications were reviewed for client UCI# 5525167 and 6320345. The following deficiencies were identified. Client UCI#5525167 was prescribed Docusate sodium 100mg, 1 to 2 caps daily at bed time as needed. The resident received the medication at 7am and not bedtime. Client UCI# 6320345- A bottle of Ibuprofen 800 mg was not entered on the centrally Stored medication log. Deficiencies were corrected and Sanction has been lifted from facility on 12-9-21. No deficiencies were observed during visit. This report has been amended to remove confidential identifying information.the state’s words, verbatim · CDSS document, Dec 30, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tirzah Hubbard arrived unannounced to conduct a Required – 1 Year inspection on 8/13/21 at 2:00pm. LPA met with Assistant Administrator Romain Felix, and stated the purpose of today’s visit. LPA were allowed entry into the facility that is licensed to serve a total capacity of 6 clients. LPA interacted with a random number of residents during this visit. The physical plant was tour inside and outside to ensure the safety of the residents. All required furniture were observed. LPA observed residents engaging in activity, wearing a mask and practicing social distancing. LPA observed the facility conducts fire drills monthly. Clients positive for COVID:5 Negative clients: 1 Staff Positive: 1 All required COVID measures were not observed. The Assistant Administrator did not take LPAs temperature or screen for COVID at the door. LPA observed both care givers in the facility not wearing the proper PPE for positive residents. LPA observed 1 positive resident in the entry way of the facility. LPA observed signs and postage. LPA observed outside fencing in good condition. LPA observed in the garage in need of cleaning and trash to be thrown away. The thermostat 74*F temperature inside the facility hallway was measured at 71 *F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 113 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed 3 of 3 medications counted properly labeled and stored, matching medication administration records (MAR).The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed there were food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. Mitigation Plan was submitted and approved. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees Criminal Record Clearances LIC536 Administrative Organization LIC309 Designation of Administrative Responsibility LIC308 Personnel Report LIC500 Qualifications of Administrator/Facility Manager- Administrator certificate Emergency Disaster Plan LIC610D In-service Training Program First aid/CPR certificates LPA trained administrator Romain Felix and caregiver Anita Gerobin to discuss and go over Donning and Doffing procedures. LPA implemented on how to put gown, shield, shoe covers, and gloves on and how to take the off. LPA requested both S1 and S2 to keep the PPE on for the remainder of the visit. LPA discussed the procedures of the quarantine and isolation and the importance of following Covid 19 procedures. LPA discussed the TV: Garage contains old mattresses Administrator has agreed to remove items out of garage by 8-18-21. LPA observed trash in the back yard with scheduled time for pick up by administrator. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, there were deficiencies cited during this visit on 809D. Exit interview held and a copy of report was given.the state’s words, verbatim · CDSS document, Aug 13, 2021

Allegation investigated: Licensee failed to have sufficient staffing per Program Design.

On 7-21-21 Licensing Program Analysts (LPA)s Tirzah Hubbard and Charlie Yang conducted an unannounced visit to discuss complaint allegations and deliver complaint findings. LPAs met with June Angeles the Licensee. LPAs toured the facility physical plant to observe the facility in ratio for the day at 3:30pm. Based on observation and interviews it was learned that two staff were required at all times to be present at this facility per program design. It was learned on 7-15-21 that there were only one staff present. As a result this facility did not maintain the required staff ratio of two. This facility was deficient, Therefore this complaint is SUBSTANTIATED. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. Deficiencies are cited on the 809D. An exit interview was conducted with June Angeles via telephone and a copy of this report was provided and signature confirms receiving these documents. Substantiatedthe state’s words, verbatim · CDSS document, Jul 21, 2021 · control 27-AS-20210719140643

From the deficiency page — Deficiency type: Type A · Section cited: CCR 85605(b) · Plan of correction due date: Jul 21, 2021

Care & Supervison 85605(b) (Zero Tolerance) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This was not met as evidence by: Licensee did not ensure the facility were fully staff and present during shift which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2021

Plan of correction: Licensee will ensure the facility is fully staff. Licensee stated that all staff will be trained no less then one hour in duration with proof of completed training of care and supervision to be submitted into CCL by the due date.