Leisure Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA was greeted by two (2) staff and six (6) residents. The LPA spoke with Administrator Michelle Maurer over the phone and informed them of the reason for the visit. The LPA toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:10 a.m., the LPA observed that the cleaning supplies were accessible, as the locking mechanism for the cabinet appeared to be inoperable. Staff were unable to fix the locking mechanism upon observation. Cleaning supplies were removed from under the sink upon observation. At 11:20 a.m., medication pill boxes were accessible in an unlocked kitchen drawer. At 11:25 a.m., knives and sharp objects were accessible in an unlocked cabinet. At 11:50 a.m., the LPA reminded staff of the items that needed to be secured, as knives and sharps were still accessible at 11:50 a.m. Staff stated that they understood. BEDROOMS: Bedrooms were observed with appropriate furnishings, clean linens and sufficient lighting. RESTROOMS: Restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms were stocked with soap and paper towels. Hand hygiene signs were posted in restrooms. Hot water temperature measured at 109 F. COMMON SPACES: Living room and dining room furniture were observed to be in good condition. The fireplace is covered and inaccessible. All exits have functioning auditory devices. The LPA observed the required postings on the wall. The backyard has a covered area equipped with furniture for resident use. The side gate door was self-latching. No bodies of water noted. The attached garage was locked. INFECTION CONTROL: There was a central entry point for symptom screening and temperature checks. Staff were wearing appropriate face coverings. Infection Control signs were observed throughout the facility. Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility keeps record of staff and resident vaccinations. Staff are up to date regarding visitation protocol and vaccine requirements. The facility's procedures as it pertains to infection control were adequate. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted with Administrator Michelle Maurer over the phone, whom authorized staff to sign the report. A copy of the report, and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Dec 21, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA met with Administrator Michelle Maurer and explained the reason for the visit. The LPA toured the facility to ensure there are no health and safety hazards and to ensure regulatory compliance. KITCHEN: Knives and chemicals are locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. All direct exits were clear and no obstructions were noted. RESTROOMS: Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 11:40 a.m., water temperature measured at 113.2 F. Restrooms were fully stocked. Hand-washing signs were observed. COMMON SPACES: Smoke detectors and common monoxide detector were operable at the time of the visit. Fireplace in the living room was covered. Fire extinguishers were fully charged and purchased 10/2021. The backyard had furniture and a covered area for resident use. The side gate door was self-latching. No bodies of water noted. The garage is attached, but was locked. Inside the garage was the washer and dryer, cleaning supplies, and Personal Protection Equipment (PPE). INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed on the front door and in the facility. The facility’s cleaning protocol is sufficient. Staff continue to document temperatures of staff and residents on a daily basis. There was record of staff and resident vaccinations. The LPA discussed changes around testing, visitation and vaccine requirements. The facility recently managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The facility's procedures as it pertains to infection control are adequate. No deficiencies. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 30, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA met with Administrator Pam Hashemi and explained the reason for the visit. The LPA toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Knives and chemicals are kept inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:06 p.m., the hot water measured at 108.6 degrees Fahrenheit. BEDROOMS: Bedrooms were observed with appropriate furnishings, clean linens and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Signs that encourage good hand hygiene were observed in all restrooms. COMMON SPACES: Living room and dining room furniture were observed to be in good condition. The fireplace is covered and inaccessible. All exits have functioning auditory devices. The LPA observed the required postings on the wall. The backyard has a covered area equipped with furniture for resident use. The side gate door is self-latching. No bodies of water noted. The garage is attached to the house, but is locked. It has additional food in good condition, and the washer and dryer. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The LPA observed hand sanitizer throughout the space for residents and staff use. This facility has documented records of staff and resident vaccinations. The LPA observed signs throughout the space that promoted good hand hygiene, signs and symptoms of COVID-19, droplet precautions, and proper mask usage. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate. No deficiencies were cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 1, 2022

Allegation investigated: Resident fell while in care. Staff handled resident in rough manner. Resident is not provided a bed.

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial complaint visit. The LPA met with Licensee Representatives Ross Hashemi and Pam Hashemi and explained the reason for the visit. During today’s visit, the LPA spoke with staff at 8:45 a.m., 10:20 a.m., 10:34 a.m., and 11:00 a.m., interviewed Resident #1 (R1) and another resident at 9:00 a.m. and 1:35 p.m., interviewed a friend for R1 at 10:45 a.m., interviewed a responsible party for a resident whom resides here at 1:46 p.m., conducted a tour at 8:55 a.m., reviewed files at 11:30 a.m., and reviewed video evidence. Regarding the allegation: Resident fell while in care It was alleged that R1 fell, resulting in injury. Interviews and records review confirmed that R1 was admitted to this facility on 11/17/2021 as a result of a right femur fracture. Interviews with R1 confirmed that R1 wants to be independent and does not want to receive assistance from staff for ambulating throughout the facility, transferring, or using the restroom. Unsubstantiated Staff interviews and a review of facility documentation revealed that R1 oftentimes refuses assistance and when staff attempt to assist R1, R1 has become physically aggressive and verbally abusive. During today’s visit, the LPA witnessed R1 ask the staff for ‘privacy’ and to ‘not be bothered’ and R1 claimed to not need any type of assistance as they needed to get ‘stronger on their own’. Interviews and records review confirmed that on 11/22/2021, R1 fell out of bed. R1 claimed that they felt themselves ‘sliding’ out the bed, so they used the half-rail for support as they slid out of bed. R1 rang a bell and staff assessed the situation and attempted to assist R1 up, yet R1 claimed that they did not want assistance. Staff then called the paramedics, yet R1 refused to go to the emergency room. The paramedics then assisted R1 back into bed. There were no apparent injuries at that time, and R1 denied being injured as a result of the fall. When asked why they do not ask for assistance, R1 claimed, “I do not need assistance.” Based on the information, there is insufficient evidence to support the claim that due to lack of care and supervision, R1 suffered a fall, resulting in injury. The allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff handled resident in rough manner. It is alleged that staff handled R1 in a rough manner, resulting in a bruise. Interviews, records review, and video surveillance confirmed that the evening of 11/29/2021, Staff #1 (S1) was cleaning in R1’s room. R1 appeared agitated and did not want S1 to clean the room. Interviews and video surveillance displayed that R1 attempted to hit S1 with a remote control as a result of increased agitation. Interviews revealed that later in the evening, S1 was attempting to assist another resident, R1 came out of their room and became agitated. S1 claimed that R1 was ambulating in their wheelchair when S1 attempted to assist R1 back into the room. S1 claimed that they tried to fix R1’s wheel and bent down to unlock R1’s wheelchair and alleged that R1 hit them across the face. As a result, S1 believed that R1 also hit their wrist on the railing in the hallway. S1, and other staff whom have provided care and assistance for R1, denied claims of retaliating, harming, or hitting R1. Whereas R1 also alleged that staff hit them on the head 2-3 times during NOC shift, staff denied all claims of hitting R1. Additional interviews denied claims of observing staff handing R1 or other residents in a rough manner. Staff interviews and a review of facility documentation revealed that R1 oftentimes refuses assistance and has been physically aggressive towards staff while receiving care. Based on the information, there is insufficient evidence to support the claim that staff handled R1 in a rough manner. The allegation is deemed Unsubstantiated at this time. Regarding the allegation: Resident is not provided a bed. It is alleged that R1 was told that sleeping in the bed was unsafe, and to sleep in an armchair. Interviews revealed that R1 did not like the physician prescribed hospital bed and felt that it was uncomfortable. Staff confirmed that they attempted to switch out the mattress and R1’s friend confirmed that they provided a thick blanket to make the bed more comfortable, but R1 did not like the bed. Staff stated that they continue to encourage R1 to sleep in their bed because it is for their safety, yet R1 refuses. The LPA toured R1’s room and observed the hospital bed with ½ rails. A review of R1’s documents confirmed that there was an order for the bed, with the accompanying ½ rails. R1 informed the LPA that they preferred to sleep in the armchair and did not think the bed was comfortable. During the visit, R1 demonstrated how they sleep in the armchair at night. Interviews confirmed that staff have relayed R1’s discomfort with the bed to R1’s primary care physician, yet an alternative solution has not been provided at this time. Based on the information obtained, there is insufficient evidence to support the claim that R1 is not provided a bed. The allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued. R1 repeatedly asked S1 to stop, because they were being exposed to the strong cleaning smell. S1 claimed that they were doing what they were ‘instructed’ to do at that time and continued mopping R1's room. Interviews with R1 revealed that the chemical smell was strong, and felt that cleaning the room at that time was inappropriate when R1 asked S1 to stop. Based on the information obtained, there is sufficient evidence to support the claim that despite requests to cease mopping, R1’s request was denied and R1 was exposed to harmful chemicals. This allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Dec 3, 2021 · control 29-AS-20211201135924

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 6, 2021

87468.1(a)(2) Personal Rights of Residents in All Facilities. Residents ... shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interview and video surveillance, the licensee did not comply with the section cited above, as R1’s requests were denied and R1 was exposed to harsh chemicals, which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2021

Plan of correction: The Licensee agreed to do the following: 1. Submit a Statement of Understanding as to how the Personal Rights of all Residents will be maintained. Submit the Statement by 12/6/2021.