Maureen House

Type of visit: Required - 1 Year

On 11:25AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiv er, Marita Sablay the purpose of the visit. Jose Michael Torio arrived approx. 30mins later. Jose's Administrator Certificate# 6033028740 Expires 10/22/24. The facility’s fire clearance was approved for 6 residents Non-Ambulatory and 1 Bedridden in Rm# 6 only. LPA toured facility with Jose including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA 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 108.3, 109, 109.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 04/04/2023. Emergency Disaster Plan was last posted in 2019. First aid kit was observed to be complete. Emergency disaster drill was last conducted on . At 12:17PM, LPA reviewed 6 residents records. At 3:13PM, LPA reviewed 7 staff records and 6 of 7 have current first aid training and associated to the facility. LIC809C Continued... LIC809 Continued.... THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 11:40 AM LPA observed scissors unlocked underneath sink cabinet At 12:10 PM LPA observed washing machine, boxes on outside garage At 12:11 PM LPA observed empty laundry detergent buckets behind shed At 12:12 PM LPA observed pot, spoon, green screen door, wood, debris behind outside shed The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penaltieties Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/19/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Updated facility sketch Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 12, 2023

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 08/22/2023 at 10:33 AM Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla conducted an unannounced Case Management visit to amend a Complaint Report from the previous visit on 08/03/2023. LPAs met with Caregiver, Lea Robes and explained the purpose of the visit. A copy of the amended report was provided to Albert Bernardino.the state’s words, verbatim · CDSS document, Aug 22, 2023

Type of visit: Case Management - Other

On 08/22/2023 at 11:15 AM Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla arrived unannounced to conduct a Case Management visit. LPAs met with Caregiver, Lea Robes. The Licensee/Administrator, Albert Bernardino, arrived approximately 1 hour later. While LPA L. Alexander was conducting file review related to complaint # 15-AS-20230801143742, LPA observed Resident 2 (R2) hospital discharge dated 5/26/2023 indicates R2 Pressure injury of right heel stage 3 ... During the visit, LPAs obtained the following records: Admission Agreement Resident Appraisal Appraisal/Needs and Services Plan Functional Capability Assessment Identification and Emergency Information Emergency Sheet Maureen House Durable Power of Attorney for Financial Release of Client/Resident Medical Information Continued LIC809-C Continued from LIC809 Attested Discharge Summary (05/26/23) Hospital Discharge Summary - Contra Costa Health Services (05/26/23) After Visit Summary - Pittsburg Podiatry (06/08/23) After Visit Summary - Pittsburg Podiatry (07/20/23) Admission Notes (12/16/22) Financial Counseling Addendum (07/13/22) History & Physical (07/11/22) Faxed 19 pages Physician's Report for RCFE signed 12/01/22 Covid-19 Test Result (05/26/23) Power PICC SOLO Catheter Info. (05/18/23) Blood Pressure Chart, Progress Report notes Contra Costa Regional Medical Labs (05/17/23 thru 05/25/23) Client Weight Record Immunization Summary LPAs will review documents and issue citations at a later time, if needed. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 22, 2023

Type of visit: Case Management - Other

On 07/31/2023 at 10:15 AM Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla conducted an unannounced Case Management visit to amend a Complaint Report from the previous visit on 07/18/2023. LPAs met with Administrator, Albert Bernardino and explained the purpose of the visit. A copy of the amended report was provided to Albert Bernardino.the state’s words, verbatim · CDSS document, Jul 31, 2023

Allegation investigated: Licensee does not provide activities for residents in care.

This is an amended report. On 07/18/2023, at 9:30am, Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla arrived unannounced to conduct initial 10-day complaint visit for the above allegations. LPAs met with Albert Bernardino and explained the reason for the visit. Allegation: Licensee does not provide activities for residents in care. LPAs reviewed a copy of the facility's June 2023 Calendar that only included activities, i.e., Bingo, Arts and Crafts alternating on Thursdays only. ***continuation on Lic 9099C*** Substantiated Based on LPAs observations and interviews which were conducted and record reviews, 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 9099D. Exit interview conducted with Administrator. Appeal rights and copy of this report was provided. Staff do not ensure requirements for the use of oxygen equipment are met. Based on observation, the facility has 1 large oxygen tank and 23 small oxygen tanks located in the garage. R1 has an oxygen concentrator and an oxygen tank set-up on a rack in the bedroom. Licensee does not ensure staff administering oxygen to residents are appropriately trained. Based on interview with Administrator and record review, R1 is able to turn their oxygen on/off with cueing. The staff can assist R1 with placing the nasal cannula. Administrator provided certificate of training documents of Oxygen Operations - Electric to Portable Use for 5 staff caregivers. Resident sustained unexplained bruises while in care. Based on record review, R1 is on Xarelto medication which is a blood thinner. Taking a blood thinner can cause bruising as a side effect. S1, S2 and S3 state R1 is able to assist with transfers. Staff denied holding R1's arms when transferring. Based on LPAs observations, interviews and record reviews which were conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. Appeal rights and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 18, 2023 · control 15-AS-20230713104549

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Jul 25, 2023

87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement is not met as evidenced by not having a planned calendar of activities for residents which poses as a potential risk to the health and safety of clients under care.the state’s words, verbatim · CDSS document, Jul 18, 2023

Plan of correction: Administrator will submit a completed copy of scheduled activity calendar from July thru December 2023 to CCL.

Allegation investigated: Staff not ensuring that incontinent resident is kept clean and dry. Staff not meeting resident's care needs.

On 05/05/2023 at 09:45 AM Licensing Program Analyst (LPA) L. Alexander and Licensing Program Manager (LPM) J. Fong conducted an Unannounced complaint investigation visit, and met with Administrator and explained the purpose of the visit. Allegation: Staff not ensuring that incontinent resident is kept clean and dry. Unsubstantiated. LPA and LPM reviewed all resident files, including but not limited to the Physician's Assessments, Admission Agreements, and Appraisals; and Unsubstantiated interviewed S1, S2, S3, S4, and W1 (by telephone), and R2 & R6. All staff denied that R1 had been left in a soiled diaper for an extended amount of time. All staff stated that all residents need some level of incontinent care. They reported that R1 is capable of alerting staff of a need for incontinent undergarment changing, or need for assistance for toileting. All staff reported that whether or not residents alert them, they check for changing needs every 2 to 3 hours. R6 reported that she requires incontinent care and that staff check on changing needs at least 3 times a day. W1 stated that she has visited R1 on multiple occasions and that R1 was clean and dry. W1 also stated that R1 presents as happy and expresses her like for the staff. W1 also stated her knowledge that the staff check R1 regularly. W1 reported also being the case manager for another resident and that there have been no problems pertaining to incontinent care for that other resident. Allegation: Staff not meeting resident's care needs. Unsubstantiated LPA and LPM reviewed all resident files, including but not limited to the Physician's Assessments, Admission Agreements, and Needs and Services Plans. LPA and LPM interviewed S1, S2, S3, S4, and W1 (by telephone), and R2 and R6. The RP alleged that when visiting on 4/18/23, R1 was in the common areas wearing only a neglige whereby the diaper could be seen. All staff denied that any resident is allowed to walk around the home dressed inappropriately and having no knowledge of R1 walking around the home dressed only in a neglige; they also stated that R1 requires assistance while ambulating the home. R2 and R6 stated having no knowledge of this issue. W1 reported visiting the home on multiple occasions and that R1 was always clean and dressed appropriately. W1 had no knowledge of the alleged incident. No other witnesses were identified. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 5, 2023 · control 15-AS-20230428101559

Type of visit: Case Management - Deficiencies

On 5/5/23 at 1:00 pm LPA Lori Alexander and LPM Jeremy Fong visited the facility for a separate matter, meeting with S1, S2, S3, and S4, and found that R1 is on oxygen, that the resident is not capable of administering it, and that staff have been assisting R1 with the oxygen. It was also found that the appropriate signage for oxygen usage was not posted. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted and a copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, May 5, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(3)(B) · Plan of correction due date: May 19, 2023

"...the licensee shall be permitted to accept/retain a resident who requires the use of oxygen...under the following circumstances ..."No Smoking - Oxygen in Use" signes must be posted." This requirement was not met as evidenced by incomplete signage at the front door.the state’s words, verbatim · CDSS document, May 5, 2023

Plan of correction: Licensee placed a full "No Smoking - Oxygen in Use" sign in the presence of LPA and LPM. Deficiency Cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87618(b)(2) · Plan of correction due date: May 19, 2023

"...Licensee ...permitted to accept or retain a resident who requires oxygen under the following circumstances...if oxygen administration is performed by an appropriately skilled professional." This requirement was not met as evidenced by staff assisting R1the state’s words, verbatim · CDSS document, May 5, 2023

Plan of correction: By POC date, Licensee will submit to CCL a detailed plan as to how R1s oxygen administration will be handled by an appropriately skilled professional

Type of visit: Required - 1 Year

On 9/21/2022 at 11:55AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Cecilia Brazil, Caregiver and explained the purpose of the visit. Administrator, Alberto Bernardino, arrived at 12:35PM. Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs posted near screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 111.0 degrees Fahrenheit. Fire extinguisher last serviced on 11/10/2021. There is a minimum of 7-day non-perishables and 2-day perishables foods. During record review, LPA observed facility has a copy of the infection control plan on file. LPA observed PPE, food, and paper supplies are sufficient. The following deficiencies were observed: At 12:10PM, LPA observed room built in garage. Staff opened door at 12:50PM, LPA observed bunk beds with bed linen, a dresser, a desk, and closet. Continued on LIC808C. Continued from 809. At 12:20PM, LPA observed R6 in bedroom #8 and should be in bedroom #6 per physician's report. At 12:30PM, LPA observed in R5's file a diagnosis that requires a skilled professional. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties. Exit interview conducted. A copy of this report provided and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 21, 2022