Mariposa Manor

Type of visit: Required - 1 Year

On 08/29/23 at 9:42 a.m. Licensing Program Analyst (LPA) Cheryl Goodrich arrived to conduct an unannounced annual visit. LPA met with Caregiver Dalia Cruz at the front door and was granted entry. The Administrator, Garret Welker arrived at 10:44 a.m. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) non-ambulatory residents, having 6 residents in care. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: There are a total of 6 resident bedrooms, and 4 bathrooms, one staff bedroom and bathroom, a kitchen, living room, office area, backyard area with furniture for residents and staff. All rooms, living room, office area, kitchen and dinning room are all clean and clear of obstruction. The resident bedrooms were clean and clear from obstruction. The resident’s rooms were complete with and clean linens and bedding, a television, dresser, and closet space. The bathroom water temperature read at 126.2 degrees with appropriate signage indicating the water exceeds 120 degrees to proceed with caution. There are no bodies of water on the premises. Operational Requirements: The facility was staffed with 2 caregivers. The facility meets the operational requirements for an RCE and has a current fire clearance for the facility, smoke and carbon monoxide detectors and fire extinguisher. (Continued on LIC809-C) (Continued from LIC809) Personnel Records-Training: All staff have fingerprint clearances, current CPR/First Aid certification, Health screen and TB test completed. All staff complete monthly in-service training and fire drills and disaster training. Client Records-Incident Reports: The resident records are complete with pre-assessments, admissions agreement, physician reports, identification and emergency information, house rules, medication log, daily logs of the resident’s health condition, and additional medical assessments. Client Rights-Information: The resident’s right documentation is present. The resident records also contain needs assessment information for each resident. Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents. Health- Related Services: The caregivers at the facility are dispensing medications within the guidelines of the physician’s order and the regulations. The facility is documenting the date and time of the dispensing of medication for each resident. Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 06/20/23. The facility has emergency supply of food and water. Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Administrator Garrett Welker and a copy of this report was printed Signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Aug 29, 2023

Allegation investigated: Staff do not allow resident to have visitors.

Licensing Program Analyst (LPA) Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegation(s) listed above. LPA met with Administrator, Garrett Welker, where LPA explained the purpose of the visit and the elements of the allegation(s). The allegation(s) were investigated, the investigation consisted of observation, interviews with three staff members and five residents, and record review. On 07/24/2023 , Community Care Licensing received a complaint stating that Staff do not allow residents to have visitors. This complaint was made by the Reporting party which states they were not allowed to visit R3. Information from Administration and staff interviews reveal that the facility has an open visitation policy, except for Resident #3 (R3). Due to R3’s special health condition and conservatorship, he is not allowed to have certain visitors that can cause harm to his health condition. (Contiuned on 9099-C) Unfounded (Continuation from 9099) The LPA reviewed documentation regarding the facility’s program statement-regarding visitation, visitors log, general placement agreement. LPA reviewed Letters of Temporary Guardianship or Conservatorship based on Probate Code Section 2351 which the refusal of visitors was granted. It was reported that R3’s conservator created a list of approved visitors and people who were not allowed to visit R3. The facility was implementing this restriction on visitors based on the conservator’s wishes and court approval. The LPA provided regulatory information to the facility regarding every resident’s right to have or refuse visitation from family, friends, or otherwise, as well as information concerning the inability of any conservator or Power of Attorney to restrict a visit to a resident based on CCR 87468.2 (a)(21). (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (21) To consent to have their relatives and other individuals of their choosing visit during reasonable hours, privately, and without prior notice. However, due to the court’s ruling on R3’s conservatorship and Probate code Section 2351, the court’s ruling shall override the regulation CCR 87468.2 (a)(21) and PIN 21-48 ASC. Based on LPA’s observation, interview conducted and record review(s), the preponderance of evidence show the allegation of Staff not allowing residents to have visitor is unfounded. This agency has investigated the complaint and we have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, a copy of this report, was provided to the Administrator, Garrett Welker and Caregiver, Dalia Calderon, whom signed for the report as evidenced by her signature.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 18-AS-20230724103142

Allegation investigated: Staff lock resident in room

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Caregiver Kurt Camalig and explained the purpose of today's visit. During today's visit, LPA toured room #6, interviewed two (2) staff, two (2) residents and attempted to interview Resident #1 (R1). R1 resides in room #6. Regarding the allegation "staff lock resident in room", it was alleged that staff lock R1 in their room in an effort to control their behaviors. Upon inspection of room #6, LPA observed a white colored, two-pronged latch attached to the outside of the door to room #6. The bottom prong can be engaged in such a way that it prevents the door handle from being manipulated from the inside and thus, preventing anyone from being able to exit the room from the inside. LPA interview with Staff #1(S1) revealed the facility does engage the latch at night to prevent R1 from being able to wonder into other rooms at night. S1 reported the latch is disengaged every morning. LPA observed the latch to be disengaged during today's visit. Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with Appeal Rights and LIC811- Confidential Names List. Substantiatedthe state’s words, verbatim · CDSS document, Sep 13, 2022 · control 18-AS-20220908164041

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Sep 23, 2022

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6) To...not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by: Based on observation and interview conducted, the Licensee did not comply with the section cited above in 1 of 1 inspections. LPA observed a latch attached to the outside of the door to room #6 which when engaged, is designed to prevent the door from being opened from the inside. S1 reported the latch is engaged at night to prevent R1 from exiting their room. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 13, 2022

Plan of correction: Facility will remove the latch on the door of room #6 and submit a written statement of understanding of the regulation cited. Proof of the latch removal and statement of understanding to be submitted to CCL by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met with Caregiver Kurt Camalig and explained the purpose of today’s visit. Licensee Garrett Welker was also present at the facility. The facility has an approved Mitigation Plan Report on file as required. There are currently no cases of COVID within the facility. During today's visit, LPA interviewed Welker regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings at the facility front entrance, including COVID-19 symptoms postings and visitation policies, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person/infection preventionist who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring staff are trained in the facility's infection control procedures, and ensuring infection control measures are implemented. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for residents and staff with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician, emergency personnel, and responsible party in the event the resident presents with any COVID-19 symptoms. No deficiencies were observed during today's visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2022

Type of visit: Required - 1 Year

***CORRECTION TO TIME VISIT BEGAN: 1:00 PM. CORRECTION TO TIME VISIT WAS COMPLETED: 2:30 PM. *** Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced annual required licensing inspection. After identifying themselves and disclosing the purpose of the visit, LPA was granted entry by Administrator Kelsey Rosas. An inspection tour was conducted inside and out, including verifying compliance with statutes, regulations and other written requirements that are relevant to protecting the health of residents in care and staff, including in the area of infection control practices. LPA assessed the strategies the facility is employing for the prevention, containment and mitigation of COVID-19, including the implementation of infection control guidance, staff retention and essential health and safety. The Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) was reviewed with Kelsey Rosas, including: Residents in Care, Staff, Visitors, Facilities without COVID-19, Infection Control and Physical Distancing. LPA observed one central entry point for universal entry, a sign-in policy and symptom screening initiated at entry for all staff, visitors and residents; the facility’s visitor policy posted at the entrance, signs throughout the facility promoting hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and face coverings recommended to residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit. An exit interview was conducted with Administrator Kelsey Rosas and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) was provided to them via email; an email read receipt confirms receipt of the report and these rights.the state’s words, verbatim · CDSS document, Aug 17, 2021