Montevista Garden

Type of visit: Required - 1 Year

Licensing Program Analyst(s) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Laura Aguilar Administrator and explained the reason for the visit. The Facility is licensed to serve 6 non-ambulatory residents over the age of 60 and has an approved Hospice Waiver for six (6) residents. Facility is a single-family home with 5 bedrooms, 3 bathrooms, a living room, dinning room, a kitchen, a front yard, a fenced back yard, a 5ft fenced pool, and a detached garage. LPA Flores conducted a tour of the facility with administrator and observed the following: Facility is clean and in good repair inside and outside. Smoke/ Carbon monoxide detectors were tested and in working condition. Facility has auditory devices on exit doors. Backyard has a 5ft fence and a covered sitting area. Living room has a covered fireplace. Cleaning supplies are stored under the kitchen's sink and locked. Refrigerator is maintained at 33 degrees F., freezer at -3 degrees F., and meets requirements. Sufficient food was observed stored for at least 2 days of perishables and 7 days of non-perishables. Five (5) resident rooms were observed with sufficient bedding/lighting and required furniture. Three (3) bathrooms were observed with grab bars, skid mats, and water temperature was tested. Water temperature measured between 109.1 - 110.5 degrees F., which is within the required 105-120 degrees F. Fire extinguishers were last checked on 4/15/22. Backyard provides a shaded sitting area and a has a 5ft fence around the pool. Laundry is in the basement. Detached garage is used as storage and PPE supplies, emergency food supplies, and additional food was observed. LPA Flores reviewed files and medication for 4 residents and 5 staff files. Administrator certificate was observed for Luis Aguilar #6020261740 exp: 9/23/24. No deficiencies were noted during this visit. Exit interview was conducted with Laura Aguilar administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 11, 2023

Allegation investigated: Facility did not report injury to proper agencies Facility failed to provide refund after the death of the resident

*This is a corrected report and supersedes report created on 2/21/23 to provide additional information on LIC9099A.* On 2/21/23 Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Marcelino Aguilar - caregiver and explained the reason for the visit. Laura Aguilar Administrator arrived 5 minutes later. The investigation consisted of the following: LPA Flores requested a copy of staff/resident roster. LPA interview administrator(S1) and reviewed Resident #1(R1)'s file, requested copies of admission agreement dated 8/30/21, invoices for November/December 2022 and January 2023, emergency and identification information sheet, physician's report dated 8/23/21, power of attorney documents for R1, LPA interviewed staff #2(S2), and staff #3(S3) over the phone. LPA attempted to interview 3 residents. (CONTINUED LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Facility did not report injury to proper agencies. It is alleged facility staff did not reported injury to community care licensing division (CCLD). During resident file review, no incident report, death report, or hospice notification were observed for R1. During interview with administrator Laura Aguilar stated to not have submitted an incident report, death report, or hospice notice for R1 to the department. LPA reviewed submitted documents to the department prior to the visit and did not find incident report or death report. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding allegation: Facility failed to provide refund after the death of the resident. It is alleged facility has a no refund for monthly fees after the death of a resident. During file review, admission agreement was observed to have been signed and initial on 8/30/21. R1 was admitted to the facility on 8/30/21 and passed away on 1/12/23. Invoice provided to the R1's family representative fees were charge for the month of January 2023. Interview with administrator revealed the facility did not provide a refund after the death R1. Per administrator family representative remove all R1's personal belongings on 1/14/23. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. Exit interview was conducted with Laura Aguilar Administrator and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Facility did not reimburse responsible party fees for incontinence care supplies. It is alleged family representative requested a reimbursement for the charge of unused diapers as 4 boxes were purchase and only a box could have been used during that time. Interview with residents revealed 1 out of 3 residents stated not to have incontinence needs and LPA was unable to interview 2 out of 3 residents due to cognitive skills. Interviews conducted with staff revealed, 3 out of 3 staff stated R1 was change between 4-6 times throughout the day and 2 out of the 3 staff stated R1 was changed between 5-6 times at night. Interviews with resident's representatives reveal 2 out of 3 representatives stated to provide or pay additional fee for incontinence care products, which are stored in the resident's rooms. Representatives stated to know the number of diapers being used. 1 out of 3 representatives was unable to be reach for an interview. Per administrator diapers were kept in residents room and if there were any diapers left they would have been in room for family to pick up. Also stated, diapers were used starting the month of January until she left. R1's representative did not observed any diapers in the room at the time personal items were picked up on . Document review revealed facility does not maintain a changing log for residents and no additional notes on incontinence care were observed. Invoice dated 12/26/22 for fees due by 1/1/23 for the month of January 2023 notes a charge of $76.00 for 4 packs of 18 briefs each. Based on the fact that diaper use for each resident is not logged, it could not be determined how many, if any diapers were left after R1's 1/12/23. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be UNSUBSTANTIATED. Regarding allegation: Resident sustained an injury while in care due to lack of supervision. It is alleged on 12/30/22 R1 sustained a broke wrist while in care. Interview with residents revealed 1 out of 3 residents stated facility's care and supervision is proper to resident's needs and LPA was unable to interview 2 out of 3 residents due to cognitive skills. Interviews with staff revealed, 3 out of 3 staff stated a staff was usually with R1 when moving around the facility and that on 12/30/22 R1 per usual was moving around with walker, after finishing breakfast R1 got up to sit on reclining chair with S3 assisting her. Upon attempting to seat R1 loss balance and arm slipped by chair's arm rest. At the time of the incident R1 did not complain of pain, there were no marks, or cuts visible. In the evening staff notice a bruise and notify administrator immediately. Administrator notified family representative, who requested R1 be taken to urgent care in the morning. Interviews with family representatives revealed 2 out of 3 representatives interviewed are satisfied with the care and supervision provided at the facility. (CONTINUED ON LIC 9099C) 1 out of 3 representatives was unable to be reach for an interview. Documents reviewed reveal power of attorney to make medical decisions for R1 is held by family member who requested R1 to be taken to urgent care the next morning instead of the evening of the injury. Based on interviews and observation, the preponderance of evidence standard has been met,. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Laura Aguilar administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 24, 2023 · control 28-AS-20230213130816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 24, 2023

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency...: (1) A written report shall be submitted...within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidence by: Based on document review Licensee did not ensure an incident report, or death report was submitted to the department which poses a potential health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, May 24, 2023

Plan of correction: Administrator will submit incident report for 12/30/22, and death report for 1/12/23, and certify in LIC 9098 that will ensure all incident reports and death reports are submitted timely to the department by POC due date 2/28/23. This deficiency was cleared on 2/28/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(C) · Plan of correction due date: May 24, 2023

87507 Admission Agreements: (g) Admission agreements ...: (5) Refund conditions. (c)A refund of any fees paid in advance.. after the... personal property has been removed from the facility shall be issued... within 15 days after the personal property is removed. This requirement is not met as evidence by: Based on document review Licensee did not ensure to refund R1's responsible party after personal items were removed which poses a potential health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, May 24, 2023

Plan of correction: Administrator will provide a refund to R1's responsible party for fees after 1/14/23 for a total of 17 days per prorate and will submit a copy of refund to the department. This deficiency was cleared on 2/28/23.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit to follow up on deficiencies found during a complaint investigation on 2/21/23. LPA Flores met with Laura Aguilar Administrator and explained the reason for the visit. On 2/21/23 LPA Flores conducted an initial complain investigation visit. During this visit LPA Flores reviewed documents for resident #1(R1), during the file review it was found last physician's report for R1 was dated 8/23/21, and an updated needs and care plan was not available for review after initial pre-assessment conducted on 8/30/21. Per Title 22 Regulations persons with dementia must have a re-appraissal updated annually. Deficiencies have been noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Laura Aguilar Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 24, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: May 31, 2023

87705 Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall...:(5) Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually,... This requirement is not met as evidence by: Based on observation, and document review licensee did not ensure physician's report and appraisal assessment were not updated annually which poses a potential risk to the health, safety, personal rights to the persons in care.the state’s words, verbatim · CDSS document, May 24, 2023

Plan of correction: Administrator will ensure residents with dementia assessments are updated annually and maintain in files. Administrator will provide a copy of udpated physician's reports and resident appraisal for current residents by POC due date 5/31/23.

Allegation investigated: Facility did not report injury to proper agencies Facility failed to provide refund after the death of the resident

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Marcelino Aguilar - caregiver and explained the reason for the visit. Laura Aguilar Administrator arrived 5 minutes later. The investigation consisted of the following: LPA Flores requested a copy of staff/resident roster. LPA interview administrator(S1) and reviewed Resident #1(R1)'s file, requested copies of admission agreement dated 8/30/21, invoices for November/December 2022 and January 2023, emergency and identification information sheet, physician's report dated 8/23/21, power of attorney documents for R1, LPA interviewed staff #2(S2), and staff #3(S3) over the phone. LPA attempted to interview 3 residents. The investigation revealed the following: Regarding allegation: Facility did not report injury to proper agencies. It is alleged facility staff did not reported injury to community care licensing division (CCLD). (CONTINUED LIC 9099C) Substantiated During resident file review, no incident report, death report, or hospice notification were observed for R1. During interview with administrator Laura Aguilar stated to not have submitted an incident report, death report, or hospice notice for R1 to the department. LPA reviewed submitted documents to the department prior to the visit and did not find incident report or death report. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding allegation: Facility failed to provide refund after the death of the resident. It is alleged facility has a no refund for monthly fees after the death of a resident. During file review, admission agreement was observed to have been signed and initial on 8/30/21. R1 was admitted to the facility on 8/30/21 and passed away on 1/12/23. Invoice provided to the R1's family representative fees were charge for the month of January 2023. Interview with administrator revealed the facility did not provide a refund after the death R1. Per administrator family representative remove all R1's personal belongings on 1/14/23. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. Exit interview was conducted with Laura Aguilar Administrator and a copy of this report, LIC 9099D, and appeal rights were provided. Interview with residents revealed 1 out of 3 residents stated not to have incontinence needs and LPA was unable to interview 2 out of 3 residents due to cognitive skills. Interviews conducted with staff revealed, 3 out of 3 staff stated R1 was change between 4-6 times throughout the day and 2 out of the 3 staff stated R1 was changed between 5-6 times at night. Per administrator diapers were kept in residents room and if there were any diapers left they would have been in room for family to pick up. Document review revealed facility does not maintain a changing log for residents and no additional notes on incontinence care were observed. Invoice for January 2023 notes a charge of $76.00 for 4 packs of 18 briefs each. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be UNSUBSTANTIATED. Regarding allegation: Resident sustained an injury while in care due to lack of supervision. It is alleged on 12/30/22 R1 sustained a broke wrist while in. Interview with residents revealed 1 out of 3 residents stated facility's care and supervision is proper to resident's needs and LPA was unable to interview 2 out of 3 residents due to cognitive skills. Interviews with staff revealed, 3 out of 3 staff stated a staff was usually with R1 when moving around the facility and that on 12/30/22 R1 per usual was moving around with walker, after finishing breakfast R1 got up to sit on reclining chair with S3 assisting her. Upon attempting to seat R1 loss balance and arm slipped by chair's arm rest. At the time of the incident R1 did not complaint of pain, there were no marks, or cuts visible. In the evening staff notice a bruise and notify administrator immediately. Administrator followed to notify family representative, who requested R1 be taken to urgent care in the morning. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be UNSUBSTANTIATED Exit interview was conducted with Laura Aguilar administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 21, 2023 · control 28-AS-20230213130816

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 28, 2023

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency...: (1) A written report shall be submitted...within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidence by: Based on document review Licensee did not ensure an incident report, or death report was submitted to the department which poses a potential health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2023

Plan of correction: Administrator will submit incident report for 12/30/22, and death report for 1/12/23, and certify in LIC 9098 that will ensure all incident reports and death reports are submitted timely to the department by POC due date 2/28/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(C) · Plan of correction due date: Feb 28, 2023

87507 Admission Agreements: (g) Admission agreements ...: (5) Refund conditions. (c)A refund of any fees paid in advance.. after the... personal property has been removed from the facility shall be issued... within 15 days after the personal property is removed. This requirement is not met as evidence by: Based on document review Licensee did not ensure to refund R1's responsible party after personal items were removed which poses a potential health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Feb 21, 2023

Plan of correction: Administrator will provide a refund to R1's responsible party for fees after 1/14/23 for a total of 17 days per prorate and will submit a copy of refund to the department.

Type of visit: Required - 1 Year

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual inspection visit with focus on infection control domain, food and medication review. LPA Flores met with caregiver and explained the reason for the visit. Laura Aguilar Assistant Administrator arrived 5 minutes later. The Facility is licensed to serve 6 non-ambulatory residents over the age of 60 and has an approved Hospice Waiver for six (6) residents. Facility is a single family home with 5 bedrooms, 3 bathrooms, a living room, dinning room, a kitchen, a front yard, a fenced back yard, a 5ft fenced pool, and a detached garage. Smoke/ Carbon monoxide detectors were tested and in working. Facility has auditory devices on exit doors. LPA Flores tour the facility with Laura Aguilar and observed the following: Living room has a fireplace with a metal screen cover. 5 bedrooms were observed with all required furniture, sufficient lighting, and all required bedding items. LPA observed 3 bathrooms which had the required grab bars, and skid mats, water temperature was tested in bathroom #1 at 114.3; bathroom #2 at 116.3; and bathroom #3 at 115.4 which is within the required water temperature of 105 - 120 degrees F. Facility's kitchen was observed to have sufficient food supplies of at least 2 days of perishables and 7 days of non-perishables. Sharps and cleaning supplies were locked under the kitchen sink. Medication was observed locked in a cabinet by the kitchen, LPA reviewed medication and files for 3 residents and 3 staff files. Administrator's certificate #6020261740 was reviewed for Luis Aguilar and expires in 9/23/22. Facility is following all infection control guidelines. No deficiencies were cited during this visit. Exit interview was conducted with Laura Aguilar Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 9, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual inspection visit with focus on infection control domain and a review of food and medication supplies. LPA Flores met with Marcelino Aguilar caregiver and explained the reason for the visit. Laura Aguilar administrator arrived 5 minutes later. The Facility is licensed to serve 6 non-ambulatory residents over the age of 60 and has an approved Hospice Waiver for six (6) residents. Facility is a single family home with 5 bedrooms, 3 bathrooms, a living room, dinning room, a kitchen, a front yard, a fenced back yard, a 5ft fenced pool, and a detached garage. Smoke/ Carbon monoxide detectors were tested and working. Facility has auditory devices on exit doors. LPA Flores tour the facility with Laura Aguilar and observed the following: Living room has a fireplace with a metal screen. 5 bedrooms were observed with all required furniture, sufficient lighting, and all required bedding items. LPA observed 3 bathrooms which had the required grab bars, and skid mats, water temperature was tested in bathroom #1 at 119.1; bathroom #2 at 119.5; and bathroom #3 at 115.2 which is within the required water temperature of 105 - 120 degrees F. Facility's kitchen was observed to have sufficient food supplies of at least 2 days of perishables and 7 days of non-perishables. Sharps and cleaning supplies were locked under the kitchen sink. Medication was observed locked in a cabinet by the kitchen, LPA reviewed medication for 3 residents. Administrator's certificate #6020261740 was reviewed for Luis Aguilar and expires in 9/23/22. Facility is following COVID 19 recommendations logs for visitors, staff, and residents screening were observed, signs are posted throughout the facility. Bathrooms have hand washing signs, soap, and paper towels available. Facility has a 30 day supply of medication. Facility's staff has an appointment to Fit Test for N95. Cleaning and disinfecting is done every 2 hours. No deficiencies were cited during this visit. Exit interview was conducted with Laura Aguilar Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 9, 2021