Megginson Place II

Type of visit: Required - 1 Year

On June 30, 2026 Licensing Program Analyst (LPA) Ahliah Sharp made an unannounced visit to the facility to conduct a required annual visit. LPA was greeted and granted entry by Grace Sales (S1), who immediately escorted LPA to Administrator (ADMIN) Janette Vega Racelis, where LPA explained the purpose of the visit. At the time of the visit there were four (4) staff and five (5) residents present. The facility has an approved hospice waiver for four (4), with three (3) residents currently receiving services. LPA conducted a tour of the interior and exterior areas of the facility. There is video surveillance being utilized in the common areas and exterior areas of the facility, with the necessary approvals for useage. The facility was observed to be clean, with the passageways being free from any obstruction. There is ample covered seating area in the back yard for recreational time for the clients. The hot water was tested and registered 109 degrees Fahrenheit. The two (2) fire extinguishers were observed to be fully charged with the tag intact and last serviced on June 23, 2026. The emergency disaster drills are being conducted on a quarterly basis, with the last drill being completed June 2026. The medications, chemicals, and sharps were observed to be locked and inaccessible to residents in care. The facility was observed to have ample food supply, well exceeding the mandated two (2) day perishables and seven (7) day non-perishables, as well as cleaning and personal hygiene supplies. LPA observed the governing body is active and in good standing, and to have valid liability insurance that expires on August 14, 2026. Continued on LIC809C... Continued from LIC809... LPA conducted file reviews of both staff and resident files. All staff have obtained criminal record clearance and are associated to the facility. The staff files were observed to have the required training and to possess valid CPR/first aid certification. The ADMIN was observed to possess a valid administrator's certification that expires on 10/26/2027, and Assistant Administrator, Roberto Ducusin, with his also expiring on 10/26/2027. The resident files were observed to have signed admissions agreements, appraisals and other assessments completed. Based on today's inspection no deficiencies were issued. An exit interview was conducted, and a copy of this report was reviewed with, and provided to, Janette Racelis, Administrator.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analysts(LPA) Janira Arreola arrived unannounced to the facility to conduct a case management health and safety check on the residents. LPA met with Administrator, Roberto Jose Ducusin who was informed of the purpose of the visit. There were (5) residents residing at the facility and (2) staff working during the time of the visit. LPA toured the facility and observed all facility utilities to be on and operating without issues. The food supply meets the 7-day non-perishables, and 2-day perishables regulatory requirement. LPA observed resident medications are filled for residents. LPA observed residents in common areas and being assisted by staff members in their rooms. There were no immediate health or safety concerns for residents in care. No deficiencies are being cited during the time of the visit. An exit interview was conducted where a copy of this report was discussed with and provided to the Administrator.the state’s words, verbatim · CDSS document, May 11, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) Janira Arreola and Seo Jeon arrived unannounced to the facility to conduct a case management health and safety check on the residents. LPAs met with Administrator, Roberto Jose Ducusin and Janette Vega Racelis who were informed of the purpose of the visit. There were (4) residents residing at the facility and (3) staff working during the time of the visit. LPAs toured the facility and observed all facility utilities to be on and operating without issues. The food supply meets the 7-day non-perishables, and 2-day perishables regulatory requirement. There are no immediate concerns for residents in care. LPAs reviewed resident records and conducted interviews during the time of the visit. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted where a copy of this report was discussed with and provided to the Administrator.the state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Seo Jeon arrived unannounced to the facility to conduct a case management visit to check on the health, safety, and welfare of residents in care. LPA met with Janette Racelis, Administrator, and informed them of the purpose of the LPA's visit. LPA was informed that five (5) residents currently reside at this facility. There were four (4) staff members on duty during the time of the visit. LPA toured the facility and observed all facility utilities to be on and operating without issues. The food supply meets the 7-day non-perishables, and 2-day perishables regulatory requirement. There are no immediate concerns for residents in care. No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted where a copy of this report was discussed with and provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 30, 2025

Type of visit: Required - 1 Year

On 05/21/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a health and safety check and 1 year required visit. LPA was greeted and granted entry by Janette Vega Racelis, Administrator where LPA explained the purpose of the visit. At the time of the visit there was (2) staff and (3) residents present. The facility has an approved hospice waiver for (4), with (1) resident currently receiving services. LPA conducted a tour of the interior and exterior areas of the facility. There is video surveillance being utilized in the common areas and exterior areas of the facility. The facility was observed to be clean, and odor free with the passageways being free from any obstruction. The emergency disaster drills are being conducted on a quarterly basis, with the last drill being completed in the first week of March 2025. The hot water was tested and measured to be at 106.7 degrees Fahrenheit. The fire extinguishers were observed to be fully charged with the tag in tact. The medications, chemicals, and sharps were observed to be locked and inaccessible to residents in care. The facility was observed to have an ample food supply, as well as cleaning and personal hygiene supplies. LPA observed for the governing body is active and in good standing, and to have valid liability insurance that expires on 08/14/25. A file review was conducted of both staff and resident files. All staff present obtained criminal record clearance and are associated to the facility. The staff were files were observed to have the required training and to possess valid CPR/first aid certification. The administrator Janette Racelis was observed to possess valid administrator's certification that expires on 10/26/25. The resident files were observed to have signed admissions agreements, appraisals and other assessments completed. Based on today's inspection no deficiencies were issued. An exit interview was conducted and a copy of this report was reviewed and provided to Janette Racelis, Administrator.the state’s words, verbatim · CDSS document, May 21, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javina George arrived on 02/25/25 for an unannounced case management visit to follow up on a substantiated allegation on a complaint investigation. LPA George met with Janette Vega Racelis, Administrator and reviewed the report. On December 28, 2023, the Department concluded a complaint investigation regarding the following allegation: staff neglect contributed to a resident’s death. The licensee was cited for California Code of Regulations § 87469(c)(3) – Advanced Directives and Requests Regarding Resuscitative Measures which states in part, “If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: specifically for a terminally ill resident that is receiving hospice services and has completed an advance directive and/or request regarding resuscitative measures form pursuant to Health and Safety Code section 1569.73(c), and is experiencing a life-threatening emergency as displayed by symptoms of impending death that is… not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).” At the time of the complaint visit on December 28, 2023, an immediate civil penalty of $500 was assessed and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for the death in accordance with Health and Safety Code Section § 1569.49. This is evidenced by the licensee’s failure to contact 911 or obtain emergency medical services when they observed an imminent threat to the health of the resident; and for failure to follow hospice nurse’s recommendation for medical intervention. Today February 25, 2025, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as contributing to the death, in the amount of $15,000. However, since an immediate civil penalty of $500 was previously assessed on December 28, 2023, the amount of the civil penalty assessed today will be $14,500. A copy of the LIC 421D was given to Janette Vega Racelis, and originals were signed. An exit interview was conducted. A copy of this report was issued. Appeal rights were provided. Janette Vega Raceli’s signature on this report acknowledges receipt of the appeal rights, found on page two of the LIC 421D.the state’s words, verbatim · CDSS document, Feb 25, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Debbie Palacios made an unannounced case management-Health and Safety check at the facility. LPA was greeted and granted entry by Administrator, Janette Vega Racelis and explained the purpose of the visit. At the time of the visit there were three (3) staff and five (5) resident's present. All staff were observed to have obtained criminal record clearance and were associated to the facility. The facility has an approved hospice waiver for four (4) residents. The facility has a total of two(2) residents that are receiving hospice services. The facility was observed to be operating within the capacity in which it was licensed for. The utilities were observed to be operable and the food supply met the requirements; of a 7 day supply of nonperishable and a 2 day supply of perishable food items. The facility has hygiene supplies, extra linen and Personal Protective Equipment (PPE) supplies located in the garage. Cleaning supplies and personal hygiene products are stored in a locked cabinet in the hallway next to bathroom. The resident's were observed (2 sleeping in the TV room, 1 resident watching TV in the bedroom. ,1 sitting at the table reading) and 1 resident getting clean and changed in the bedroom by caregiver. The resident's medications and sharps were locked and inaccessible to residents. LPA spoke with administrator regarding any concerns with residents in care and no issues or concerns were reported. There were no health and safety concerns 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, Jan 22, 2025

Type of visit: Case Management - Health Checks

On 10/28/24 at 11:15am Licensing Program Analyst (LPA) Javina George made an unannounced case management-Health and Safety check at the facility. LPA was greeted and granted entry by Administrator, Janette Vega Racelis and explained the purpose of the visit. At the time of the visit there were three (3) staff and five (5) resident's present. All staff were observed to have obtained criminal record clearance and were associated to the facility. The facility has an approved hospice waiver for four (4) residents. The facility has a total of (3) residents that are receiving hospice services. The facility was observed to be operating within the capacity in which it was licensed for. The utilities were observed to be operable and the food supply met the requirements; of a 7 day supply of nonperishable and a 2 day supply of perishable food items. The facility has hygiene supplies, extra linen and Personal Protective Equipment (PPE) supplies. The resident's were observed (1 sleeping, 1 watching TV in their bedroom. 2 watching TV in the common area, 1 sitting at the table). Lunch was also served during LPAs visit. The resident's medications, cleaning supplies and sharps were locked and inaccessible residents. LPA spoke with administrator reagrding any incidences that have occurred since the last department visit where they had to call 911 for assistance. Per Administrator Janette, the unusual Injury report was submitted, and stated that there was one (1) instance where emergency medical personnel had been contacted for assistance due to Resident #1 (R1) due to an unwitnessed fall on 08/26/24. There were no health and safety concerns observed, during today's visit. An exit interview was conducted, and a copy of this report, and LIC 811-Confidential names list was discussed and provided.the state’s words, verbatim · CDSS document, Oct 28, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Javina George made an unannounced Health and Safety check at the facility. LPA was greeted and granted entry by Administrator, Janette Vega Racelis and explained the purpose of the visit. At the time of the visit there were two (2) staff and five (5) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. The facility has an approved hospice waiver for four (4) residents. The facility has a total of (3) residents that are receiving hospice services. The facility was observed to be operating within the capacity in which it was licensed for. The utilities were observed to be operable and the food supply met the requirements; of a 7 day supply of nonperishable and a 2 day supply of perishable food items. The facility has hygiene supplies, extra linen and Personal Protective Equipment (PPE) supplies. The resident's were observed in their (1 sleeping, 1 watching TV) and the facility common areas (2) watching and 1 eating breakfast. The resident's medications, cleaning supplies and sharps were locked and inaccessible residents. LPA spoke with administrator any incidences that have occurred since the last department visit where they had to call 911 for assistance. Per Administrator Janette, there has not been any unusual Injury reports received, and confirmed that there were no instances where emergency medical personnel had been contacted for assistance since the last visit was made in June 2024. LPA received an updated resident roster as well as copy of liability insurance, for the facility file at the regional office. There were no health and safety concerns observed, during today's visit. An exit interview was conducted, and a copy of this report, and LIC 811 was discussed and provided.the state’s words, verbatim · CDSS document, Aug 21, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Health and Safety check at the facility. LPA was greeted and granted entry by Administrator, Janette Vega Racelis and explained the purpose of the visit. At the time of the visit there were two (2) staff and five (4) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. Both staff are licensee and have administrator's certificates. The facility has an approved hospice waiver for four (4) residents. The facility now has two (2) residents that are under hospice care. A resident on hospice care passed away on June 12, 2024. LPA obtained the incident report, reviewed resident documents, and interviewed staff. The facility was observed to be operating within the capacity in which it was licensed for. The utilities were operating and facility food meet the department requirements. The facility has hygiene supplies and PPE supplies. The facility resident were observed in their rooms and the facility common areas. The resident's medications, cleaning supplies and sharps were locked and inaccessible residents. LPA spoke with administrator any incidences that have occurred since the last department visit where they had to call 911 for assistance. Per Administrator Janette there has not been any instances where emergency medical personnel assistance has been needed, and reporting requirements would be followed should the need arise. During today's visit no health and safety concerns were observed. An exit interview was conducted, and a copy of this report, and LIC 811 was discussed and provided.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Janette Vega Racelis, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (4) clients present. The facility is a one story home with (7) bedrooms and (4) bathrooms with attached garage. (2) bedrooms are for staff, and (1) bathroom is for staff. (1) of the (5) resident rooms are shared. The facility is approved for bedridden status in room #3 and is approved for (4) hospice residents. No pools or firearms are being kept at the facility. LPA observed the following: Infection Control: The LPA observed the hand washing stations in the facility restrooms had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide alarms were operational, and the hot water temperature 116F Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Required postings were found in the facility. The listed administrator, possesses a current administrator's certificate. Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in a closet. LPA reviewed client medications for (2) client and found all medication listed on MARS and accounted for. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill March 2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies. No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Javina George conducted an unannounced Health and Safety check at the facility. LPA was greeted and granted entry by Caregiver Ladonna Baca, and explained the purpose of the visit. At the time of LPAs visit there were two (2) staff and five (5) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. The Administrator was unable to come to the facility but was available via telephone. The facility has an approved hospice waiver for four (4) residents. The facility continues to have three (3) residents that are under hospice care. The facility was observed to be operating within the capacity in which it was licensed for. LPA observed for staff to be preparing dinner. The gas, water and electric were operable. LPA observed for the facility food supply to meet with minimum requirements of a 2 day supply of perishable and 7 day supply of nonperishable food items. The resident's medications were observed to be locked and inaccessible to the resident's in care. LPA spoke with Administrator via telephone to inquire about any changes at the facility with staffing, services being offered and if there have been any incidences that have occurred since the start of the new year where the facility staff had to call 911 for assistance. Per Administrator Janette there has not been any instances where emergency medical personnel assistance has been needed, and reporting requirements would be followed should the need arise. During today's visit no health and safety concerns were observed. An exit interview was conducted, and a copy of this report, and LIC 811 was discussed and provided to Roberto Ducusin, Caregiver.the state’s words, verbatim · CDSS document, Apr 16, 2024

Type of visit: Case Management - Health Checks

On today's date 03/25/24, Licensing Program Analyst (LPA) Javina George conducted an unannounced Health and Safety check at the facility. LPA was greeted and granted entry by Licensee Janette Racelis, and explained the purpose of the visit. At the time of LPAs visit there were two (2) staff and five (5) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. The facility has an approved hospice waiver for four (4) residents. The facility continues to have three (3) residents that are under hospice care. LPA conducted a tour of the interior and exterior of the facility. The facility has five (5) residents bedrooms and (2) staff bedrooms and 4 bathrooms. LPA observed for the driveway repairs to have been completed. The driveway is now at an even level. The facility was observed to have operable utilities (electric, water, gas). LPA observed for the facility food supply to meet with minimum requirements of a 2 day supply of perishable and 7 day supply of nonperishable food items. LPA observed for there to be some expired box food items, that were discarded at the time of LPAs visit. As a result of the items being discarded no deficiency was issued. The resident's medications were observed to be locked and inaccessible to the resident's in care. The new cycle of medications have not been received as per Ms. Janette, they are usually received 3 days before the month ends. An exit interview was conducted, and a copy of this report, and LIC 811 was discussed and provided to Licensee Janette Racelis.the state’s words, verbatim · CDSS document, Mar 25, 2024

Type of visit: Case Management - Health Checks

On today's date 02/20/24, Licensing Program Analyst (LPA) Javina George conducted an unannounced Health and Safety check at the facility. LPA was greeted and granted entry by Licensee Janette Racelis, and explained the purpose of the visit. At the time of LPAs visit there were two (2) staff and five (5) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. There were three (3) resident's sleeping, two (2) resident's watching a television program. The facility has an approved hospice waiver for four (4) residents. The facility continues to have three (3) residents that are under hospice care. All resident's on hospice have a DNR as indicated on their Physician's Orders for Life Sustaining Treatment (POLST). There is one bedridden resident (resident #1/R1), whom resides in bedroom #3. LPA conducted a tour of the interior and exterior of the facility. The facility has five (5) residents bedrooms and (2) staff bedrooms and 4 bathrooms. There is currently one vacant resident bedroom. LPA observed for the facility to have the required postings such as personal rights, Emergency disaster plan (LIC610E), facility License, Long Term Ombudsman Poster (LTCO) poster and department complaint poster (PUB 475). In regards to the uneven pavement at the end of the driveway, the repair is scheduled to begin on 3/19/24 and expected to be completed on 3/20/24. Regarding the use of video surveillance. As discussed on 2/2/24, the licensee, Mrs. Racelis submitted an addendum to the facility's plan of operation, obtained signed consents from all five (5) of the residents and or their responsible parties, as well as provided an updated facility sketch indicating where the camera's are placed throughout the facility. A copy is on file at the regional office. The facility was observed to have operable utilities (electric, water, gas). LPA observed for the facility food supply to meet with minimum requirements of a 2 day supply of perishable and 7 day supply of nonperishable food items. The facility was observed to have at minimum of a 30 day supply of Personal Protective Equipment (PPE). LPA observed for the facility to have paper supplies (paper towels, toilet paper) and EPA approved cleaners. The facility has an abundance of hygiene supplies available for residents in care to use. The resident's medications were observed to be locked and inaccessible to the resident's in care. No health and safety concerns were observed during today's visit. An exit interview was conducted, and a copy of this report, and LIC 811 was discussed and provided to Licensee Janette Racelis.the state’s words, verbatim · CDSS document, Feb 20, 2024

Type of visit: Case Management - Health Checks

On today's date 01/25/14, Licensing Program Analyst (LPA) Javina George conducted an unannounced Health and Safety check at the facility. LPA was greeted and granted entry by Licensee Janette Racelis, and explained the purpose of the visit. At the time of LPAs visit there were two (2) staff and five (5) resident's present. Both staff were observed to have obtained criminal record clearance and were associated to the facility. There were (2) resident's sleeping, (1) resident eating and (2) resident's watching a television program. The resident's observed in the common area and at the dining room table were were observed to be dressed and well groomed. The facility has an approved hospice waiver for four (4) residents. The facility currently has three (3) residents that are under hospice care. All resident's on hospice have a DNR as indicated on their Physician's Orders for Life Sustaining Treatment (POLST). LPA did not observe any additional advanced health care directives for the residents under hospice care. LPA conducted a tour of the interior and exterior of the facility. The facility has five (5) residents bedrooms and (2) staff bedrooms and 4 bathrooms. There is currently one vacant resident bedroom. Upon arrival to the facility LPA observed for the driveway where it meets at the sidewalk to be uneven. LPA estimates the gap to be about a 4-5" gap between the sidewalk and end of the driveway. The pavement is uneven on the right side of the facility if you are standing across the street, looking at the facility. LPA observed for there to be an orange cone present, highlighting the uneven pavement. LPA inquired with the Licensee Mrs. Racelis if the shift in foundation is something that has happened over time. Mrs. Racelis stated that the shift/uneven pavement have been a result of the recent earthquake that occurred a couple of weeks ago. Mrs. Racelis stated that she has been in communication with the property owner, who stated the pavement will be repaired. The is a current appointment with a foundation company is scheduled for 1/30/24 at 9am to estimate the cost of repair. The Licensee will send proof of estimate, confirming that the the facility is working to repair the uneven pavement. At this time a citation is not being issued as the shift in foundation is out of the control of the facility staff. Due to the Licensee taking the necessary steps to repair the pavement. Once the estimate is provided and consultation with the property owner is completed, the Licensee will provide an update to the department in regards to the expected plan of action to repair the driveway. LPA observed for the facility to be utilizing video surveillance. LPA observed for there to be one (1) camera in the dining room, and two (2) cameras inside of the living room, one (1) camera in the hallway as well as a doorbell camera and in the backyard throughout the outside perimeter of the facility. There were no cameras observed in the resident bedrooms. Per the Licensee Mrs .Racelis the cameras were installed about three years ago, and are used to provide increased supervision, especially if a resident begins to wander. LPA informed Licensee that the facility was required to update the facility sketch indicating where the cameras are throughout the facility, an addendum to the facility's plan of operation, as well as a consent to video surveillance for the residents. If the Licensee does not submit the required updates to the department by 5pm on 2/08/24, as agreed by the Licensee the facility will be cited. LPA observed for the facility to be clean, odor and clutter free. The facility was observed to have at minimum of a 30 day supply of Personal Protective Equipment (PPE). The PPE consisted of gloves, gowns, masks both surgical and N95 respirator's, and face shields. LPA observed for the facility to have paper supplies (paper towels, and napkins). The facility has EPA approved cleaners (bleach, Pine Sol, Lysol, disinfectant wipes and spray). The facility has an abundance of hygiene supplies available for residents in care to use. The resident's medications were observed to be locked and inaccessible to the resident's in care. The facility was observed to have the required docs such as personal rights, Emergency disaster plan, facility License, LTCO poster and department complaint poster (PUB 475). The facility's food supply was observed to meet the requirements of a 2 day supply of perishable and a 7 day supply of nonperishable food items. LPA conducted follow up in regards to a recent discussion that was held on 1/14/24, between the department and the Licensee Janette Racelis, where guidance was provided. LPA inquired about the follow up taken after the discussion and the Licensee did not follow the guidance given. A technical violation is being issued. An exit interview was conducted, and a copy of this report, LIC9102, and LIC 811 were discussed and provided to Licensee Janette Racelis.the state’s words, verbatim · CDSS document, Jan 25, 2024

Allegation investigated: Staff neglect contributed to death of a resident.

Licensing Program Analyst (LPA), Javina George made an unannounced visit to deliver findings for the allegation noted above. LPA met with Administrator Janette Rosario and explained the purpose of the visit and the elements of the allegation.The investigation consisted of observations, interviews, and records review. On 10/21/2020, the department received an allegation that staff neglect contributed to the death of a resident. Resident #1 (R1) was admitted to the facility on 07/23/2020. At the time of admission R1 was receiving hospice services. Per a review of R1’s Physician Orders for Life- Sustaining Treatment (POLST) dated 07/23/2020, R1 wanted CPR and full treatment medical interventions. Per a review of R1’s advanced health care directive dated 07/23/2020, it revealed that “All medical personnel to use resuscitation measures to restart or restore the patient’s heart or breathing”. Based on a review of records, text message and notes from the hospice agency, on 08/09/2020, R1 was found by facility staff with a low oxygen level. The text message dated 08/09/2020, revealed the text message was sent from the administrator of the facility to R1’s responsible party. Substantiated Text message indicated R1’s oxygen level was “49” and that it was “not good” and that hospice had been called. Per an interview with the administrator, the facility staff called hospice, as well as R1’s responsible party. Based on interview with administrator, facility staff did not provide any treatment other than continuing R1’s oxygen, giving a nebulizer treatment and massaging R1’s extremities. This was corroborated by a review of Facility Daily Care Notes dated 08/09/2020 for R1. Per an interview with the administrator 911 was not called because staff had contacted hospice and staff were waiting to hear back from hospice. This was refuted by a review of hospice records. Hospice death visit notes dated 08/09/2020 were reviewed. These notes revealed hospice was contacted on 08/09/2020 at 9:41am by the facility administrator. Facility administrator reported R1 had “extremely low oxygenation up to 50%...” The death visit note continues that the hospice nurse had informed the administrator about R1’s code status and that they can call 911. Note further reads, the administrator verbalized understanding. Per the death certificate dated 09/01/2020, the immediate cause of death for R1 was respiratory arrest. There is sufficient evidence to reveal 911 was not contacted, therefore, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department. An exit interview was conducted where this report, the 9099D, appeal rights and the Civil Penalty assessment form and appeal rights were reviewed with Administrator Janette Rosario. *** Due to facility staff currently out of vacation and returning at different times, an extension was granted to give ample time to ensure that all staff have been retrained on resuscitative measures. The extension to submit proof of the plan of correction to the department by Friday January 12, 2024.the state’s words, verbatim · CDSS document, Dec 28, 2023 · control 18-AS-20201021110407

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87469(c)(3) · Plan of correction due date: Jan 12, 2024

Advanced Directives and Requests Re: Resuscitative Measures If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: for a terminally ill resident that is receiving hospice services & has completed an advance directive and/or request re: resuscitative measures form & is experiencing a life-threatening symptoms of impending death that is directly related to the expected course of resident's terminal illness the facility may immediately call resident’s hospice agencythe state’s words, verbatim · CDSS document, Dec 28, 2023

Plan of correction: in lieu of calling emergency response (911).For emergencies not related to the terminal illness, the facility staff shall immediately call 911. Requirement not met, as the administrator called hospice & hospice advised administrator to call 911. Administrator did not call 911 & R1's cause of death was respiratory arrest.This posed an immediate health, safety and personal rights risk to persons in care. The Licensee agrees to conduct an inservice on resustive measures. Proof of POC is to be submitted to the department by 5pm on 01/12/2024.