Merced Senior Living

Type of visit: Required - 1 Year

On 5/3/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Memory Care Director Tracy Seibert and announced the purpose of the visit. LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. Fire extinguishers were recently serviced and facility has a sprinkler system. LPA toured the facility kitchen and observed an adequate supply of perishable and non-perishable foodstuffs. Kitchen and all common were well-lit, and odor-free. Facility had adequate supply of emergency food and first aid supplies. LPA reviewed emergency-disaster plan. LPA toured a sample of resident bedrooms and bathrooms. LPA toured facility memory care unit. LPA observed centrally stored medications in assisted living and memory care to be properly stored and secured, and medications appeared to be administered properly. LPA reviewed a sample of resident and staff files. Files contained required documentation and records. LPA requested the following files to be provided by 5/18/2023: LIC 500, LIC 308, LIC 9020a. During the inspection, LPA observed common areas and some resident bedrooms to have debris and dead bugs on the floor and along windows and window sills. LPA also observed food debris on the floor in the dining area. LPA observed one resident shower with a tiled floor to not have a non-skid mat. In the memory care kitchen area, LPA observed cleaning solution and Clorox spray stored in an unsecured cabinet below the sink. During records review, LPA observed that facility staff did not maintain adequate records of disaster/emergency drills. The last recorded fire drill was conducted 10/30/2019 at the time of inspection. See attached 809-D's for four type B citations issued in accordance with California Code of Regulations Title 22. A copy of the report and appeal rights were provided. Exit interview conducted.the state’s words, verbatim · CDSS document, May 4, 2023

Allegation investigated: Facility staff do not respond to call bell in a timely manner. Facility not providing adequate food service.

On 5/3/23 at 9:35 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a complaint inspection. LPA explained reason for inspection and met with Administrator Shelly Randel. LPA made observations, conducted interviews, and reviewed records. Based on LPA's observations, interviews, and record review, LPA found that although the signal system logs may show extended response times of 10-60 minutes, staff may sometimes forget to clear the call or the devices used do not immediately get cleared and is a technical issue, and it was observed that staff responded within an average time of 5 minutes or less; and that facility cooks hot fresh meals daily but sometimes may become cooled by the time the food is delivered to a resident's room, at which point the staff, or per resident request, would then warm up the food again by microwave. Therefore, the above allegations are unsubstantiated. The allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Due to technical difficulties, a copy of this report was emailed to Administrator with "read receipt" to confirm receipt of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 3, 2023 · control 24-AS-20230106152902

Type of visit: Case Management - Deficiencies

On 5/3/23 at 1:54 PM, Licensing Program Analyst (LPA) Malia Thao conducted a case management - deficiencies inspection to address observations made during complaint #24-AS-20230106152902 inspection. LPA explained reason for inspection and met with Administrator Shelly Randel. During the complaint inspection, LPA observed the signal system devices installed at bedside and in the bathrooms of sampled bedrooms in Memory Care of room #306, 308, 314, and 317 were all inoperable. During interviews, LPA found that staff conduct 30 minute checks on residents and do not use pagers to be able to receive the signal system alert for the memory care residents. A deficiency is being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and a Plan of Correction was reviewed and developed with the Administrator. Due to technical difficulties, a copy of this report and appeal rights were emailed to Administrator with "read receipt" to confirm receipt of this report.the state’s words, verbatim · CDSS document, May 3, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 10, 2023

87303 Maintenance and Operation (a) The facility shall be...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: LPA observed the signal system devices installed at bedside and in the bathrooms of sampled bedrooms in Memory Care of room #306, 308, 314, and 317 were all inoperable. During interviews, LPA found that staff conduct 30 minute checks on residents and do not use pagers to be able to receive the signal system alert for the memory care residents. This poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Administrator will submit proof of written plan to ensure signal system is operating and what will be done to re-implement the signal system for the memory care residents and staff, to include projected completion dates, to CCL by POC due date.

Allegation investigated: Facility has expired foods Staff do not keep the facility free from insects

Licensing Program Analyst (LPA) K. Kaur arrived at the facility unannounced for subsequent complaint inspection. LPA discussed the purpose of the visit and the elements of the allegations with administrator. LPA delivered the following findings. Based on interviews conducted and observation the facility had expired foods in the facility refrigerator and freezer. The facility was also observed with insects in several of the resident’s rooms. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted with Administrator and appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Mar 2, 2023 · control 24-AS-20221215083348

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Mar 2, 2023

87555 (b) (8) General Food Service Requirements. The following food service requirements shall apply: All food shall be of good quality. This requirement was not met as evidenced by: Based on observation Licensee did not keep foods of good quality when refrigerator observed to store fruit that was moldy.the state’s words, verbatim · CDSS document, Mar 2, 2023

Plan of correction: ***POC has been completed during the subsequent visit*** Administrator discussed with food and nutrition director the need to make sure all food is checked on a daily bases to remove any food that is going moldy or expired.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a)(1) · Plan of correction due date: Mar 17, 2023

80087 Buildings and Grounds (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1)The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by: Based on observation Licensee did not keep facility free of insects, ants observed in resident rooms 103, 105 and 208 which poses a potential health, safety personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 2, 2023

Plan of correction: Plan of Correction POC Licensee agrees to have pest control service the facility and Licensee will submit reciept by POC due date

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) L. Cabrera conducted an unannounced Case Management visit. LPA met with Shelly Randel, Executive Director. Administrator was unavailable and designated Shelly Randel to meet with LPA. CCL Office received Unusual Incident/Injury Report (SIR) dated 07/06/2022. LPA follow-up regarding Resident (R1) not knowing how much Tylenol resident took. Facility immediately called the ambulance and R1 was transported to the Hospital. Facility is now administering all medications for R1. LPA requested new Physician’s Report for R1. CCL Office received Unusual Incident/Injury Report (SIR) dated 07/24/2022. LPA follow-up regarding R2 stage of wound on right hand. Per records reviewed, R2 has a skin tear only. CCL Office received Unusual Incident/Injury Report (SIR) dated 09/02/2022. LPA follow-up regarding R3 health and safety. No follow-up needed. CCL Office received Unusual Incident/Injury Report (SIR) dated 09/04/2022. On 09/07/2022, ED reported the incident to CCL. LPA follow-up regarding R4 absent without leave (AWOL). It was reported that on 09/04/2022, R4 went AWOL from the facility. On 08/27/2022, the egress door was out of service. ED implemented a plan for staff to conduct 15 minutes checks and document it. According to ED, all residents were accounted for at 9:45a.m. Two staff were assisting another resident while third staff was at lunch. ED reported there was no supervision in the common area. During the 10a.m. count, R4 was not accounted for. Facility conducted a search for R4. At 10:30a.m., Merced Police Department (MPD) was notified and MPD confirmed they had R4. ED reported R4 is a resident in Memory Care. R4 was transported to Mercy Hospital and returned on the same date. Per R4’s Physician’s Report dated 03/07/2021, R4 has mild cognitive impairment and is unable to leave facility unassisted. On 05/14/2021, R4 was admitted to Memory Care. A civil penalty is being cited, per California Code of Regulations, Title 22, Division 6, see attached 421IM. Exit interview conducted and Designated Representative was provided with the LIC809, LIC809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Sep 29, 2022

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Sep 30, 2022

HS§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not meant by: The incident occurred on 09/04/2022 resulted in Memory Care resident R4 going AWOL from the facility. There was no supervision in the common area, which poses an immediate risk to the health, safety or personal rights of the clients in care. Per R4’s Physician’s Report dated 03/07/2021, R4 has mild cognitive impairment and is unable to leave facility unassisted.the state’s words, verbatim · CDSS document, Sep 29, 2022

Plan of correction: Licensee has implemented a plan of correction in which there is a staff assigned and scheduled to monitor the Memory Care Egress door until door is repaired. Licensee will submit written statement of the plan of correction by 09/30/2022 to CCL.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. Administrator Daniel Gormley was unavailable and approved for Executive Director Shelly Randel to give a tour of the facility. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the bathrooms. Bedrooms were checked. The exterior tour was conducted. LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. LPA follow up on Special Incident Reports (SIR) submitted to CCLD on 03/15/2022, 04/14/2022, 03/24/2022,3/26/2022, and 04/14/2022 to obtain additional information regarding the incidents. Based on today’s inspection, deficiencies were cited in the areas evaluated and listed on the LIC809D according to California Code of Regulations Title 22. Exit interview was conducted.the state’s words, verbatim · CDSS document, Apr 26, 2022

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility is not following COVID-19 protocol.

Licensing Program Analyst (LPA) L. Cabrera conducted the subsequent complaint visit on this date. LPA met with Shelly Randel, Executive Director due to Administrator Daniel Gormley was unavailable. LPA spoke with Administrator and approved for LPA to meet with the Executive Director. LPA stated the purpose of the visit. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Facility is not following COVID-19 protocol. Based on the interviews conducted and records review the above allegations are UNSUBSTANTIATED. On 02/02/2022 and on today’s date, LPA observed COVID precautionary measures were taken at the point of entry. Although the allegation may have happened or is 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 was conducted. Administrator was provided with a copy of this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 20, 2022 · control 24-AS-20220125094342

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Inadequate staffing to meet resident's needs.

Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced subsequent complaint visit on this date. LPA met with Shelly Randel, Executive Director due to Administrator Daniel Gormley was unavailable. LPA spoke with Administrator and approved for LPA to meet with the Executive Director. LPA stated the purpose of the visit. During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Inadequate staffing to meet resident's needs is UNFOUNDED. During 01/14/2022, facility was experiencing a Covid-19 outbreak. The facility notified Community Care Licensing they had inadequate staffing due staff testing positive for Covid. During the outbreak, the facility continued to hired staff and staff were focusing on meeting and taking care of the residents. This agency has investigated the complaint alleging (Inadequate staffing to meet resident's needs). We have found that the complaint was unfounded, therefore we have dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, Apr 20, 2022 · control 24-AS-20220120103132

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff behaviors poses as a risk to the residents while in care Residents are sustaining falls while in care Residents are left soiled for extended periods of time Staff are stealing the residents medications

Licensing Program Analyst (LPA) L. Cabrera conducted the subsequent complaint visit on this date. LPA met with Shelly Randel, Executive Director due to Administrator Daniel Gormley was unavailable. LPA spoke with Administrator and approved for LPA to meet with the Executive Director. LPA stated the purpose of the visit. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Staff behaviors poses as a risk to the residents while in care, Residents are sustaining falls while in care, Residents are left soiled for extended periods of time and Staff are stealing the residents medications. On 1/23/2022, LPAs interviewed facility Business Manager and Memory Care Director, it was reported no internal investigations or incidents involving staff. It was reported to the complainant that residents are sustaining falls and residents are left soiled for extended periods of time due to staff behaviors. LPA reviewed all reported fall related incident reports and interviewed Bristol Hospice staff. Per records and interviews, there are no concerns at this time regarding residents being left soiled for extended periods of time. Unsubstantiated On 01/13/2022, LPAs conducted a medication count and reviewed Centrally Stored Medication with facility staff. LPAs did not observe any errors with residents’ medications count. LPA reviewed resident’s Medication Administration Record (MAR) and it appears medication was given as prescribed. Based on the interviews conducted and records review the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is 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 was conducted. Administrator was provided with a copy of this report.the state’s words, verbatim · CDSS document, Apr 20, 2022 · control 24-AS-20220107164106

Allegation investigated: Bedridden residents are not being turned every two hours. Residents are not receiving timely assistance with incontinence needs. Facility has roaches. Facility is not offering activities.

Licensing Program Analyst (LPA) L. Cabrera conducted the subsequent complaint visit on this date. LPA met with Shelly Randel, Executive Director due to Administrator Daniel Gormley was unavailable. LPA spoke with Administrator and approved for LPA to meet with the Executive Director. LPA stated the purpose of the visit. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Bedridden residents are not being turned every two hours, Residents are not receiving timely assistance with incontinence needs and Facility has roaches. Per records reviewed and Bristol Hospice-California interviews, there are no concerns at this time regarding the residents not being repositioned and not receiving timely assistance with incontinence needs. Per Bristol Hospice, some residents are self-alert and not alert to their surroundings. Per records and interviews, facility will post a monthly calendar for residents to participate. Staff will conduct sensory activities and one on one activies in the residents room. Unsubstantiated On today’s date, LPA was provided with a sign out sheet for a residents' outing as part of a facility activity. Based on records and interviews, facility does have monthly pest control service but does have the occasional pests in facility. Based on the interviews conducted and records review the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is 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 was conducted. Administrator was provided with a copy of this report.the state’s words, verbatim · CDSS document, Apr 20, 2022 · control 24-AS-20211229162747

Allegation investigated: Resident fell while in care resulting in injury.

Licensing Program Analyst (LPA) L. Cabrera conducted the subsequent complaint visit on this date. LPA met with Shelly Randel, Executive Director due to Administrator Daniel Gormley was unavailable. LPA spoke with Administrator and approved for LPA to meet with the Executive Director. LPA stated the purpose of the visit. The Department conducted interviews with staff and records reviewed. Per Resident’s (R1) initial assessment dated 05/22/2019, R1 is independent with transfers and ambulated independently with or without an assistive device. On 12/05/2021, R1 sustained an unwitnessed fall while using her scooter in her room. On 12/06/2021, R1 was discharged with Home Health and physical therapy. R1 was reassessed by the facility. The facility implemented a Care Plan, which indicates the interventions staff would use in order to minimize R1’s fall risk. Incident related to the fall is address in substantiated finding report. This agency has investigated the complaint alleging (Lack of supervision resulting in resident's fall). We have found that the complaint was unfounded, therefore we have dismissed the complaint. Exit interview was conducted. Administrator was provided with a copy of this report. Unfounded Facility has the menu posted for residents and have an Always Available Menu for all residents. LPA interviewed residents and staff, it was reported that meal trays are cold or lukewarm when delivered. Per interviews, some staff will microwave the meal trays for the residents once the tray is delivered. On 11/11/2021, EcoLab serviced R1’s room and indicated no findings noted during service. On 12/21/2021 and on 12/28/2021, LPA interviewed R1 in R1’s room. During the two visits, LPA did not observe any pests in R1’s room. Based on records and interviews, facility does have monthly pest control service but does have the occasional pests in facility. Based on the interviews conducted and records review the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is 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 was conducted. Administrator was provided with a copy of this report. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Apr 20, 2022 · control 24-AS-20211214083606

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(3) · Plan of correction due date: Apr 21, 2022

87411Personnel Requirements -General (d) All personnel shall be given on the job training... shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision... This requirement was not met as evidenced by: Based on records reviewed and interviews, the Resident (R1) had an unwitnessed fall. R1 was left on the floor for an extended period of time and staff did not respond in a timely manner, which poses an Immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 20, 2022

Plan of correction: Licensee shall submit a plan of correction (POC) by 04/21/2022, that details the steps that will be taken to ensure that resident calls for assistance are responded to in a timely manner.

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) L. Cabrera conducted a case management visit on this date. LPA met with Shelly Randel, Executive Director due to Administrator Daniel Gormley was unavailable. LPA spoke with Administrator and approved for LPA to meet with the Executive Director. LPA stated the purpose of the visit. LPA received a death report for Resident (R1) and LPA requested R1 records to be submitted by 4/21/2022 to CCL. No deficiencies cited. LPA will follow-up once the records and interviews have been conducted.the state’s words, verbatim · CDSS document, Apr 20, 2022

Type of visit: Office

An Informal Office Meeting was held on 02/08/2022 at the Fresno Regional Office. The purpose of the meeting is to discuss recently identified issues/ concerns associated with the operation of the facility. In attendance: Shelly Randel, Business Office Director, Daniel Gormley, Operations Specialist, Licensee Representative Brenda White, Regional Manager Sergiy Pidgirny, Licensing Program Manager Lady Cabrera, Licensing Program Analyst The following issues/ concerns associated with the operation of the facility were brought forward and discussed with the Licensee Representative: 1. Accountability of Licensee Governing Body 2. Administrator - Qualifications and Duties 3. Personnel Requirements - General 4. Personnel - Operations 5.Basic Services (Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).) 6.Incidental Medical and Dental Care 7. Personal Rights 8. Maintenance and Operationthe state’s words, verbatim · CDSS document, Feb 8, 2022

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced Case Management visit. The purpose of the visit is to follow up on the administration of the facility. LPA met with Shelly Randel, Business Manager and Daniel Gormley, Acting Administrator. On 12/21/2021, LPA met with Tracey Seibert, Memory Care Director (MCD) and Acting Administrator Daniel Gormley. LPA was informed that Administrator Tyler Wilds was transferred to another state two weeks prior. On 12/22/2021, LPA emailed Acting Administrator and MCD the change of administrator requirements and the 87211 Reporting Requirements regulations. As of today’s, date the Department has not received notice as to the status whether a new administrator has been hired. LPA reviewed the Unusual incident report that occurred on 01/12/2021, which resulted of Resident (R1) going absent without leave (AWOL) at approximately 3a.m. R1 was last seen approximately at 1a.m. Facility immediately contacted Merced PD. Resident was located across the street inside the The Hampshire Independent Living by Merced PD approximately at 5:30a.m. R1 was reassessed and admitted to Memory Care. Per Physician's Report dated 1/21/2020, R1 is unable to leave the facility unassisted. Deficiencies cited on LIC809D. Exit interview conducted and Designated Representative was provided with the LIC809, LIC809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Feb 2, 2022

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312 · Plan of correction due date: Feb 3, 2022

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. *This requirement was not met as evidenced by: The incident occurred on 01/12/2021 which resulted in resident R1 going AWOL from the facility. R1 is/was unable to leave the facility unassisted per Physician Report dated 1/21/2020. This presents an immediate risk to the health, safety or personal rights of the clients in care.the state’s words, verbatim · CDSS document, Feb 2, 2022

Plan of correction: R1 was reassessed and moved to MC. Licensee shall submit a written statement describing how Licensee will comply with care and supervision. Licensee will provide training by 02/16/22. Staff will be train and ensure they are aware of resident's needs.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(g) · Plan of correction due date: Feb 15, 2022

87211 Reporting Requirements (g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator… This requirement was not met as evidenced by: Based on interviews and records review, the Licensee has not notified the Department, in writing of a new facility administrator, which poses a potential Health, Safety and Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 2, 2022

Plan of correction: Licensee shall submit required change of administrator documentation by 02/15/2022. LPA provided a copy of the requirements and reporting requirements regulations to Designated Representative.

Allegation investigated: Residents sustaining pressure injuries while in care

Licensing Program Analyst (LPAs) Kamaldeep Kaur and Lady Cabrera conducted an unannounced subsequent complaint visit on this date. LPAs met with Tracy Seibert, Memory Care Director the Acting Administrator Daniel Gormley was unavailable. LPAs and stated the purpose of the visit. During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Residents sustaining pressure injuries while in care is UNFOUNDED. The facility confirmed having Resident (R2) being diagnosed with pressure injuries. Per R2’s Primary Physician, R2 has two wounds that are stage 2. R2 is being seen by Compassionate Home health and her primary physician. If R2’s conditions do not improve, then she will be referred to wound care clinic for further evaluation. Per California Code of Regulations, Title 22, Division 6, Chapter 8, Article 11, Section 87631(a)(3), the facility is able to retain a resident who has healing wound…with stage two pressure injury…the resident shall receive care for the pressure injury from a physician or an appropriately skilled facility. Unfounded This agency has investigated the complaint alleging (Residents sustaining pressure injuries while in care). We have found that the complaint was unfounded, therefore we have dismissed the complaint.the state’s words, verbatim · CDSS document, Dec 28, 2021 · control 24-AS-20211123122945

Allegation investigated: Facility staff did not effectively communicate with resident's responsible party. Facility staff did not ensure that resident's room is clean.

Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced subsequent complaint visit to the facility. During this visit LPA delivered investigation findings regarding the above allegations. Administrator Tyler Wilds is unavailable. Administrator designated Tracy Seibert to sign this report. During this complaint investigation, it was discovered Licensee did not communicate with the Resident’s (R1) Responsible party/Representative listed on the Residence and Care Agreement. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. On 02/09/2021, R1 received the 1st Dose Covid-19 vaccine without notifying R1’s Responsible Party/Representative. Based on staff interview, staff confirmed not vacuuming R1’s room and received a verbal warning. Staff reported the facility resume using a housekeeper check list to indicate when a room has been cleaned. It was determined based on the interviews that the above allegation is SUBSTANTIATED. Facility staff did not ensure R1’s room is clean. Substantiated Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited on the attached LIC 9099D. Exit interview was conducted. A copy of this report, LIC9099, LIC9099D and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents. Based on the interviews conducted and records review the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is 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 was conducted. A copy of this report, LIC9099 and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 1, 2021 · control 24-AS-20210803085608

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 15, 2021

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8)To have their representatives regularly informed by the licensee of activities related to care or services... This requirement was not met as evidenced by: Based on records review and interviews, the Licensee did not communicate with the R1's Responsible party/Representative listed on the Residence and Care Agreement, which poses a potential Health, Safety and Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2021

Plan of correction: Licensee shall submit a Plan of Correction (POC) by 10/15/2021, Licensee to review 87468.1 Personal Rights of Residents. Licensee shall submit a written letter indicating they have read and understand the regulations to CCLD. LPA provided a copy of the regulation and PIN 21-14-ASC. Licensee to review all assisted living residents’ records to determine and maintain separately, which resident has a responsible party and which resident do not. Documents of this will be provided to CCL by 10/15/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 15, 2021

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure R1’s room is clean, which poses a potential Health, Safety and Personalthe state’s words, verbatim · CDSS document, Oct 1, 2021

Plan of correction: Licensee shall submit a Plan of Correction (POC) by 10/15/2021, Licensee shall submit a written plan on how to ensure all residents rooms are maintain clean.

Allegation investigated: The resident was not given the opportunity to read and participate in the development of the pre appraisal. Resident is sleeping in her chair.

Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced subsequent complaint visit to the facility. During this visit LPA delivered investigation findings regarding the above allegations. During the course of this complaint investigation LPA interviewed facility staff, obtained and reviewed facility records. It was determined based on the interviews and records reviews that the above allegation is SUBSTANTIATED. On 04/28/2021, Resident’s (R1) Pre-Admission Appraisal assessment was completed by facility staff and R1’s relative only. R1 did not participate in the development of the pre-appraisal. Based on the interviews, observations, and records review the second allegation is SUBSTANTIATED. It was determined R1 sleeps on her recliner at night due to not getting appropriate assistance. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED, are being cited on the attached LIC 9099D. Substantiated Administrator was informed that as a COVID-19 precautionary measure, LIC809, LIC809-D and Appeal Rights will be emailed to the Administrator.the state’s words, verbatim · CDSS document, Aug 9, 2021 · control 24-AS-20210714114514

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(a) · Plan of correction due date: Aug 23, 2021

87457 Pre-Admission Appraisal - General(a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. This requirement was not met as evidenced by: Based on interview and records, the Licensee did not ensure that on 04/28/2021, Resident (R1) R1 did not participate in the development of the pre-appraisal, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2021

Plan of correction: Licensee shall submit a Plan of Correction (POC) by 08/23/2021, a written plan to have the prospective resident and/his her responsible person particpate in the Pre-Admission Appraisal. Licensee stated a reassement will be completed with the resident.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Aug 23, 2021

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning… This requirement was not met as evidenced by: Based on interview, the Licensee did not ensure that R1 is regularly observed for changes and was not provided with appropriate assistance, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2021

Plan of correction: Licensee shall submit a Plan of Correction (POC) by 08/23/21 that details the steps to ensure the resident is provided with appropriate assistance.

Allegation investigated: Staff are not answering the call buttons in a timely manner.

Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced subsequent complaint visit on this date. LPA met with Adminsitrator and stated the purpose of the visit. During the investigation, LPA interviewed Staff (S1), S2, S3, Resident (R1), and reviewed 5/1/2021-6/23/2021 call button records. R1 reported the facility staff would respond to the call button after an hour and a half. R1 reported they can’t depend on the staff if they have an emergency in assisted living. Upon review of the call buttons records, LPA observed several calls that had delayed response times. LPA interviewed staff and inquired if staff are answering the call buttons in a timely manner. Staff reported they are short staffed and sometimes take 30 to 45 minutes to respond due to assisting other residents or completing other job duties. Based on interviews and review of the records, the preponderance of the evidence standard has been met therefore the above allegation is SUBSTANTIATED. Deficiency cited in the attached LIC9099-D and appeal rights provided. Substantiated An exit interview was conducted, and Plan of Correction (POC) was reviewed and developed with the Administrator. Administrator provided with LIC9099, LIC9099-D and Appeal Rights.the state’s words, verbatim · CDSS document, Jul 14, 2021 · control 24-AS-20210622113417

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 15, 2021

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care... This requirement was not met as evidenced by delayed response times to call buttons, which poses an Immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2021

Plan of correction: Licensee shall submit a plan of correction (POC) by 07/15/2021, that details the steps that will be taken to ensure that resident calls for assistance are responded to in a timely manner. Licensee sttated he is in the process of hiring more staff in the assisted living area.

Allegation investigated: Resident fell multiple times while in care

Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced subsequent complaint visit on this date. LPA met with Administrator Tyler Wilds and stated the purpose of the visit. Based on interviews conducted and records review, resident's fall was not because of lack of care or supervision, and the allegation is UNFOUNDED. R1 had witnessed and unwitnessed falls and was provided immediate evaluation and assistance by facility staff. Unfoundedthe state’s words, verbatim · CDSS document, Jul 14, 2021 · control 24-AS-20210429103148

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jul 15, 2021

87465 Incidental Medical...(c)...physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...(2)Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on records review, the Licensee did not meet the Incidental Medical Care. R1 missed her prescribed medications on 4/22/2021, which poses an Immediate Health, Safety and Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2021

Plan of correction: Licensee shall submit a plan of correction (POC) by 07/15/2021. POC shall include medication training to all staff that are involved in passing medications to the residents when they return from the hospital. Licensee shall submit a signed training roster to CCLD with a copy of the policy and list of attendees by 07/16/2021.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Lady Cabrera conducted a case management visit to offer technical assistance to Licensee. LPA recommended that facility should provide resident's personal belongings, immediate items resident requires such as, dentures, glasses, hearing aids, medication list and/or medications when resident is being transported to the hospital.the state’s words, verbatim · CDSS document, Jul 14, 2021