Mesa Care

Type of visit: Required - 1 Year

On 10/25/2023 Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct a required 1-Year Annual facility site inspection visit at the facility above. When the LPA arrived, they were greeted by Licensee Alex Polunets, Administrator/Licensee Valentina Polunets and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This facility is a Residential Care for the Elderly (RCFE) that has an age range of 60 years and older for all residents in care. The facility fire clearance is approved for approved for 6 non-ambulatory residents, 2 of which may be bedridden. A hospice waiver is approved for 4 residents. KITCHEN(S): The facility has a main kitchen for residents of the facility, and a connected dining room. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in the kitchen in a locked drawer inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last 7 days. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. Heating devices such as stoves are inaccessible to residents, as are sharps/other items that could constitute a danger to residents. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. Continued on 809-C COMMON AREAS: At the time of the visit, the living room and dining room were observed to be appropriately furnished, with all furniture in good condition. The entrance to the facility has an area with sign in materials as well as COVID screening procedures. The facility itself is a single-story personal residence home converted into an RCFE. There is a living room for residents off the main dining room that is appropriately furnished, with all furniture being in good condition. There is a fireplace on the premises, which is covered and inaccessible. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature at the time inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit in each of the buildings inspected. The fire extinguisher was fully charged and last serviced in 2023. The LPA observed required postings throughout all common spaces including Resident Personal Rights and Resident Council Rights. There are activity supplies and equipment, including reading materials for the residents in all common areas inspected. All window screens were in good repair in all the areas comprising the facility. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all interior areas are well-lit with sturdy hand railings/stair chair accessibility devices. This facility is one (1) story throughout and therefore there are no stairways for residents to utilize. As the facility has less than 16 residents and is single-story, so there is no signal system in place at the time of the inspection by the LPA. OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of a front courtyard with an open porch with tables and chairs. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. Outdoor activity spaces are completely enclosed by a fence and gates or walls. Outdoor activity spaces in the backyard are equipped with furniture for resident use including a patio with an umbrella for shade. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for residents, and are well-lit. There were no bodies of water noted. The laundry room of the facility contains additional supplies/emergency supplies. The designated laundry room of the facility is where cleaning products are stored, which are kept locked and inaccessible to residents. The laundry room is accessible from the common areas of the facility and is comprised of a small hallway adjacent to the kitchen. There was emergency food and water in storage area of the garage which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. Continued on 809-C LPA noted that outside in the back yard is completely enclosed by two gates on either side of the facility and has appropriate furniture for residents as well as shade. LPA did not observe any noticeable outdoor hazards. The facility is completely enclosed with auditory delayed egress exits into and out of the facility. Auditory delayed egress devices monitor all exits from the interior of the facility, and the outdoor gates to leave the facility. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are 7 designated individual resident rooms in the facility, and storage areas for clean linens, towels, pillows, etc. Each resident bedroom has a single bed, night stands, and lights and night stand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are 3 resident bathrooms total in the facility, with 3 shared bathrooms in the common areas of the facility and 1 bathroom being a private resident bathroom in a resident bedroom. All restrooms inspected had assisting equipment for residents including grab bars and/or non-skid surfaces. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees. As the facility only contains 5 residents at the time of inspection, there is at least 1 toilet and sink for each 3 residents, and at least 1 bathtub/shower for each 3 residents. Nightlights are installed in the hallways outside of the common area restrooms. RECORDS: The facility keeps confidential storage of personnel records and resident records on-site at the facility. Personnel records reviews were reviewed for, but not limited to Personnel records, Health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, Employee Rights, Criminal record Statements/Criminal record clearances, first aid/CPR certification that is not expired, and the appropriate training. All staff member personnel records had the appropriate documentation with no expiration of any training. Continued on 809-C Resident records were reviewed for Pre-Admission/Placement appraisals, Physicians Reports, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS), Resident Assessments, Self-management of medications if applicable, Medication Orders, and Medication Logs. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. MEDICATIONS: The facility maintains a locked centralized storage area for resident medications. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. Centrally Stored Medications are in a locked cabinet in the laundry room area inaccessible to residents. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exiting plans with necessary telephone numbers. The facility has copies of applicable documentation including Applicant Information, Designation of Facility Responsibility, Affidavit Regarding Client/Resident Cash Resources, Surety Bond, Personnel Report, Personnel Record, Health Screening Report, Emergency Disaster Plan, Residential Infection Control Plan, Facility Sketch, Plan of Operation, Control of Property, The Job Description for Each Staff Position, Personnel Policy, In-Service Training for Staff, Facility Program Description, Rules of Discipline/Personal Rights, Admission Agreement for Residents, Theft & Loss Policy, and Job Description for the Administrator. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 25, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Olson and Kontilis conducted an unannounced Annual Infection Control Inspection of the facility. LPAs arrived at 2:47 PM and was greeted by Administrator Valentyna Polunets. LPA explained the purpose of the visit. At the time of arrival, there was one staff on duty and six residents in care. Co-Administrator Alex Polunets arrived to the facility at approximately 3:10 pm. Entrance interview conducted. The facility is a one-story facility located in a residential area. A tour of the physical environment and accommodations were assessed and the following was noted: LPAs observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPAs inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. LPAs observed the fire inspection was last conducted on 4/5/2022. LPA Olson observed eight smoke alarms and 1 carbon monoxide detector were in good working order. The kitchen area was sufficiently stocked with at least two days of perishables and seven days of non-perishables. The facility has an entry station at the front door entering the facility. Upon entry, staff, visitors, and clients who are returning from an outing are required to sign-in and have a temperature screening. All documentation is kept in a binder in the locked staff office. Documentation is filed on a regular basis. PPE gear, hand sanitizer, disinfecting wipes, disinfecting spray, gloves, masks, and thermometers, and backup PPE are kept in the garage and in the kitchen area. A backup supply of PPE gear is kept in the garage. Please continue to 809-C, Pg 2. Cleaning agents are kept in a cabinet in the garage. Medications are kept in two cabinets in the facility’s laundry room. At 3:39 pm, LPA Kontilis observed one of the two medication cabinets unlocked at the time of the visit. The facility maintains a comfortable temperature. First aid supplies were observed to be in good order. Residents participate at will in music activities, puzzles, games, and visits to local eateries. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. LPAs observed the kitchen cabinets, refrigerator, stove, and counters are clean. There are six private bedrooms and an extra bedroom. Bedrooms #5 and #7 have a private bathroom. There are two bathrooms off the facility hallway. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of COVID-19. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located immediately outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Staff who have a respiratory illness are requested to stay home and not report to work. Activities have been modified to individuals or small groups with social distancing. Residents' medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in the locked staff office. Facility observes guidance changes and the most up-to-date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificate is valid. Please continue to 809-C, Pg 3. At 2:52 pm, LPAs observed Staff 1 (S1) in the kitchen of the facility not wearing a mask. LPAs observed S1 leave the kitchen area and enter into a private bedroom. LPAs observed S1 exit the private bedroom and walk through the common area and leave the facility, S1 was not wearing a mask when they exited the facility.LPAs requested S1 put on a mask different two times. At approximately 3:15 pm, LPA Olson observed S1 in the front yard of the facility. LPA Olson inquired as to S1's name and requested identification. S1 provided their California Department of Motor Vehicles Driver's License to LPA Olson. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D), Exit interview conducted. Report and Appeal Rights issued via email.the state’s words, verbatim · CDSS document, Oct 18, 2022

Allegation investigated: Facility exceeds approved capacity.

Licensing Program Analyst (LPA) Olson conducted subsequent visit to deliver final findings. LPA met with Alex Poluntes, Licensee and explained the purpose of the visit. On 6/29/21 Licensing Program Analysts Toan Luong and Darlene Chavez conducted an initial 10 day complaint inspection at Mesa Care and met with Administrator Valentina Polunets. LPAs requested documents pertinent to the investigation. LPAs interviewed administrator and 4 residents. LPA Luong conducted interviews with witness, residents, and staff on 6/24/21 through 6/29/21, 8/24/21, 8/25/21, and 10/5/21. LPA reviewed facility documents. On the allegation: Facility exceeds approved capacity. It was alleged that the facility was at maximum capacity of 6 and had a 7th resident around 6/21/2021. LPA Luong’s interview revealed that there was an individual age 96, Resident 7 (R7) was at the facility between 6/21/2021 to 6/22/2021. Staff interviews confirmed an individual was at the facility during that time but only reported as a day visit. Continued on 9099-C Substantiated LPA Luong requested the contact information of R7 and their parties. Administrator informed LPA that it was a day visit, and R7 was performing a trial period with their family to see if the facility was an appropriate fit for R7. One resident was expected to move out at the end of the month, and the licensee wanted to ensure the vacancy would be filled. The licensee receives numerous requests for a trial and did not have R7’s contact information. The facility did not have a visitor’s log upon LPA’s request. LPA informed the facility this was a requirement as a result of the Coronavirus Disease and should have been implemented as part of the facility’s mitigation plan. Other interviews reported that R7 had been at the facility for several days. Among the other interviews includes a credible witness who was present at the facility and witnessed R7 sitting at the table by self with no other visitors. Credible witness also reported that staff informed the credible witness that R7 was at the facility for several days. Although it could not be determined how long R7 stayed, there is sufficient evidence based off interviews that R7 was at the facility without their representative. Without their representative the facility would have been required to provide care and supervision to R7 for the day and therefore exceeded the license capacity of 6. Therefore the allegation Facility exceeds approved capacity is substantiated. LPA conducted exit interview, deficiency issued on 9099-D, and provided a copy of this report along with appeal rights to the facility. R2 was also described as having a history being “nasty” and complained about everything. R2 also has arthritis and had undergone a medication change. During the medication change, R2 became aggressive and would scream and pound on the walls. There was insufficient evidence to prove the allegation facility staff verbally abused resident. Therefore the allegation is deemed unsubstantiated at this time. However, LPA recommends that personal rights training be provided to all staff as a best practice. Exit interview conducted and a copy of this report will be emailed to Administrator/Licensee.the state’s words, verbatim · CDSS document, Jul 20, 2022 · control 29-AS-20210625101437

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87158(a) · Plan of correction due date: Jul 21, 2022

87158(a) Capacity. A license shall be issued for a specific capacity which shall be the maximum number of residents which can be provided care at any given time… This requirement was not met as evidence by: Based on interviews and eyewitness, the facility had a 7th resident at the facility without their representative and staff would have needed to provide care and supervision which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 20, 2022

Plan of correction: Licensees to provide a written statement of understanding and acknowledgement of regulation 87158. Licensee agreess to not exceed the capacity. Licensee understands prospective residents may not be provided care and supervision by staff.