Mori Manor

Allegation investigated: Facility telephone is in disrepair

On 11/07/2023 at 10:30 AM Licensing Program Analysts (LPA) P. Watson arrived unannounced to conduct a complaint investigation for the above allegation. LPA met with Administrator, Ferdinand Gutierrez, and explained the purpose of the visit. During the course of the investigation, LPA toured facility and interviewed staff. It was alleged that Facility telephone is in disrepair, based on interview with Administrator the facilities telephone was in disrepair for about 5 (five) days and was recently fixed. Administrator stated that they believe there were internet problems causing the phones to be in disrepair. Some of the residents have personal cell phones and were able to communicate with family members while the facility telephone was not operable, for the resident who does not have a personal cell phone their family members were unable to speak to them unless they called the Administrator and/or owner. Report continues on 9099 C Substantiated Based on LPA interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 15-AS-20231031165312

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87311 · Plan of correction due date: Nov 10, 2023

87311 Telephones All facilities shall have telephone service on the premises... This requirement is not met as evidence by: Based on interview the licensee did not have telephone service for the residents which poses/posed a potential Health, Safety or Personal Rights risk to persons in care. Administrator stated that the phone was in disrepair for about 5 (five) days due to internet problemsthe state’s words, verbatim · CDSS document, Nov 7, 2023

Plan of correction: Deficiency cleared during visit, Administrator stated that the facility telephone was repaired about 3 (three) days ago and is operable. LPA called the facility telephone and confirmed it is working.

Type of visit: Case Management - Other

On this day, October 24, 2023 at 9:35 am, Licensing Program Manager (LPM) Fong and Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management inspection as part of monitoring plan from Non-compliance Conference held on August 31, 2023. LPA met with staff Maria Manjarez, and informed the reason for visit. LPA also met with other staff, Blesilda Yamat, and Beatriz Munoz. LPA called and spoke over the phone with Ferdinand 'Ferdie' Gutierrez, administrator, who gave permission to have Maria Manjarez be with LPA during inspection. Administrator arrived at around 10:00 am. LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms. front, side and backyard. LPA inspected the food supples and observed good for 2 days of perishables and 7 days of non-perishables. Hot water temperature in one of the bathrooms was tested and measured at 112.9 degrees Fahrenheit. LPA reviewed 1 residents' (R2) file. LPA observed the following: -at 9:57 am, medications and wound cleanser unlocked in R1's room. -at 9:58 am, smoke detector in R1's room removed from the ceiling.. -at 10:04 am, scissors, wound cleanser in R2 and R3's room. -at 10:11 am. shovel in the side yard -at 10:12 am, wall texture repair agent and rake in unlocked storage on the side yard. -at 10:14 am, protruding uncovered drain about 3 to 4 inches in height in the side yard. -at 10:17 am, weed killer unlocked in the cabinet in the foyer next to the kitchen where food supplies are kept. ....continued on 809C (page 2) Page 2 -at 10:45 am, mouse droppings in closet where heater is located. -at 12:37 pm, resident's (R2) LIC9172 Functional Capability Assessment indicated R2 can reposition not consistent with LIC602A Physician's Report which showed R2 is bedridden. Preplacement Appraisal indicated ambulatory. R2's bed has half bed rails but no doctor's order on file. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Civil penalties are assessed for the following: 1. $1,000.00 for fire safety violation # 87203. This is a repeat violation; first citation was issued on 6/28/23. 2. $250.00 for repeat violation of # 87465(h)(2) Incidental Medical and Dental Care for unlocked medications. First citation was issued on 7/18/23. 3. $250.00 for repeat violation of # 87309(a) Storage Space for unlocked storage with wall texture repair. agent and rake are kept, shovel in the side yard, weed killer in cabinet without lock in the foyer. Citations were issued on 6/28/23 and 7/06/23. 4. $250.00 for repeat violation # 87303(a) Maintenance and Operation for mouse droppings and protruding drain pipe. Citations were issued on 6/28/23 and 7/18/23. 5. $250.00 for repeat violation of # 87506(a) for LIC9172 and Appraisal not consistent with LIC602A. First citation was issued on 7/18/23. 6. $250.00 for repeat violation of # 87458(b)(5) Medical Assessment for LIC602A indicating R2 is bedridden. First citation was issued on 7/18/23. Civil penalties will continue until corrected. Deficiencies and civil penalties were discussed with the administrator. Administrator has to leave at 3:50 pm and authorized the pm staff, Rosamaria Munoz to sign and receive this report. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and LIC421FC Civil Penalty Assessments, and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 24, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Oct 25, 2023

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. -This requirement is not met as evidenced by: -Based on observation and interview, the licensee did not comply with the section above for smoke detectors in R1's room removed which poses immediate safety risk to person in care. Civil penalty is assessed.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator stated he'll have smoke detectors installed, Pictures to be submitted by 10/25/23. A $1,000.00 civil penalty is assessed today.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Oct 25, 2023

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications..(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. -This requirement is not met as evidenced by: -Based on observation. the licensee did not comply with the section above for medications unlocked in R1's room which poses immediate health and/or personal rights risks to persons in care. This is a repeat violation.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Staff took and locked the medications. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 10/25/23. A $250.00 civil penalty is assessed,

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 25, 2023

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for unlocked storage, shovel in the side yard, weed killer in cabinet without lock in the foyer, wound cleanser in cabinets without lock, and scissors. These pose immediate health and safety risks to persons in care. This is a repeat violation.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Staff put shovel and weed killer in the storage and lock the storage, In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 10/25/23. A $250.00 civil penalty is assessed,

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 7, 2023

87303 Maintenance and Operation 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and 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: -Based on observation, the licensee did not comply with the section above for mouse droppings and protruding drain pipe which pose potential safety risks to persons in care. This is a repeat violation.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator called Pest Control company to provide service. Proof of service to be submitted by 11/07/23. In addition, administrator to do the following and submit proof by 11/07/23: 1. Have the mouse droppings cleaned-up and submit picture. 2. Have the protruding pipe fixed and submit picture. A $250.00 civil penalty is assessed,

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Nov 7, 2023

87608 Postural Supports (a) ....Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record....... -This requirememt is not met as evidenced by: -Based on record review, the licensee did not comply with the section above for R2's half bed rails without doctor's order on file which poses potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator to obtain doctor's order and submit copy by 11/07/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Nov 7, 2023

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff -This requirement is not met as evidenced by: -Based on record review, the licensee did not comply with the section above for R2's LIC9172 and Appraisal indicated ambulary, which are not consistent with LIC602A which showed bedridden. These pose potential safety and/or personal rights risks to person in care. This is a repeat violation.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator to have R2 seen by primary care physician (pcp) and update the documents accordingly. Copies of updated Appraisal and LIC9172 to be submitted by 11/07/23. A $250.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(b)(5) · Plan of correction due date: Nov 7, 2023

87458 Medical Assessment (b) The medical assessment shall include, .. (5) The determination whether the person is ambulatory or nonambulatory ... The assessment shall indicate whether nonambulatory status is based upon the resident’s physical condition, mental condition or both. -Based on record review, the licensee did not comply with the section above for R2's LIC602A indicated bedridden which poses potential safety and/or personal rights risks to persons in care. This is a repeat violation,the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator to have R2 seen by pcp and have the LIC602A updated and copy to be submitted by 11/07/23. A $250.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(24) · Plan of correction due date: Nov 7, 2023

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for keeping the weed killer in the cabinet where food supplies are kept which poses potential health and/or personal right rsks to persons in care,the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Staff removed and locked the weed killer. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/07/23.

Type of visit: POC

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit and met with Ferdinand Gutierrez, administrator, and informed the reason for visit. On 9/29/23, LPA Delmundo issued citations for the following deficiencies with POCs to be submitted by 9/30/23; however, administrator submitted the POCs on 10/01/23. Civil penalties of $100.00 each for the following is assessed on this day, 10/24/23: 1. Section # 87705(1) Care of Persons with Dementia 2. Section # 87705(f)(2) Care of Persons with Dementia Deficiency section # 87458(a) Medical Assessment was also cited on 9/29/23 is being re-cited on this same day for failure to submit POC by 10/13/23: Deficiency section # 87463(c) Reappraisals - Administrator showed to LPA R2's LIC625 Appraisal/Needs and Services Plan which was completed on 10/09/23; however, administrator failed to submit the POC by 10/13/23. This deficiency is cleared on this day. Deficiencies and civil penalties were discussed with administrator who authorized staff, Rosamaria Munoz to sign and receive this report. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 24, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Nov 7, 2023

87458 Medical Assessment (a)Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. -This requiement is not met as evidenced by: -Based on records, the licensee did not comply with the section above for R2's LIC602A signed by PA-C not consistent with MD's assessment. R2 was not followed-up with his MD. These pose potential health, safety, and/or personal rights risks to person in care. This is a re-citation.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator to do the following and submit proof by 11/07/23. 1. Have an appointment schedule with R2's doctor. 2. Obtain an updated LIC602A.

Type of visit: Case Management - Other

On this day, September 29, 2023 at 12:05 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management inspection as part of monitoring plan from Non-compliance Conference held on August 31, 2023. LPA met with staff Maria Manjarez, and informed the reason for visit. LPA also met with other staff, Blesilda Yamat, and Pedro Rabulan. LPA spoke over the phone with Ferdinand Ferdie' Gutierrez, administrator, who gave permission to have Maria Manjarez be with LPA during inspection. Administrator arrived after above 3 hours. LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms. front, side and backyard. LPA inspected the food supples and observed good for 2 days of perishables and 7 days of non-perishables. LPA reviewed 2 residents' file. LPA observed the following: -at 12:30 pm, 12:34 pm and 12:40 pm., weed and grass killer in the front yard, shave cream unlocked in the common bathroom, and shovel in the side yard respectively. -resident (R1) has 8 medications but no doctor's order on file. -resident (R2) has 8 medications listed on After Visit Summary dated July 24, 2023 provided by the administrator via email to LPA on July 27, 2023. This document has 8 medications listed; however, facility has only 5 medications on hand of which 2 have labels with strength and dosage different from the list, 1 (a PRN) no longer on the list. Vitamin B-12, melatonin and multi Vitamin were on the list but facility does have these. Vaccine is also listed but it's not clear if resident received the vaccine. .....continued on 809C -R2's LIC602A signed by a Physician Assistant (PA-C) indicated mild cognitive impairment not consistent with document signed by Hospitalist (MD). R2's After Visit Summary indicated R2 to have a follow-up visit August 21, 2023. LPA verified with administrator, and administrator indicated he has not communicated with R2's case manager to schedule the appointment. -R2's LIC625 Appraisal/Needs and Services Plan is over a year old. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A civil penalty of of $250.00 for repeat violation of section: 87465(e), and will continue for $100.00/day if not corrected within due date. Deficiencies, plan and proof of corrections and civil penalty were discussed with the administrator. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421FC Civil Penalty Assessment, and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(1) · Plan of correction due date: Sep 30, 2023

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for having shovel and shave cream unlocked which poses an immediate safety risks to persons in care,the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: LPA had the items locked by the staff. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 9/30/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Sep 30, 2023

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to.....(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for weed and grass killer unlocked which poses an immediate risk to persons in care,the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: LPA had the item locked by the staff. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 9/30/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Sep 30, 2023

87465 Incidental Medical and Dental Care: (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file..... -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for not having doctor's order for R1's 8 medications which poses immediate health risk To person in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator to obtain doctor's order and submit copy by 9/30/23. A $250.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(e) · Plan of correction due date: Sep 29, 2023

CONTINUATION OF THE ABOVE: This is a repeat violation within 12 months. First citation was issued on 7/27/23.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 29, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed......... (4) The licensee shall assist residents with self-administered medications as needed. -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for not having 3 of R2's medications and 2 medications dosage and stregth different from the order which poses immediate risks to person in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator to obtain the medications and submit pictures by 9/29/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Oct 13, 2023

87458 Medical Assessment (a)Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. -This requiement is not met as evidenced by: -Based on records, the licensee did not comply with the section above for R2's LIC602A signed by PA-C not consistent with MD's assessment. R2 was not followed-up with his MD. These pose potential health, safety, and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator to do the following and submit proof by 10/13/23. 1. Have an appointment schedule with R2's doctor. 2. Obtain an updated LIC602A.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(e) · Plan of correction due date: Oct 13, 2023

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative,,,, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467...... -This requirement is not met as evidenced by: -Based on record review, the licensee did not comply with the section above for R2's LIC625 Appraisal/Needs and Services Plan more than a year old which poses potential health and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator to have the appraisal updated and submit copy by 10/13/23.

Type of visit: Office

On this day, August 31, 2023, a Non-compliance Conference was conducted. The existing deficiencies, problem areas in the operation of the facility, civil penalties, repeat violations and failure to submit proof of corrections were discussed. Present at the meeting were: 1. Regional Manager Isaac Taggart 2. Licensing Program Manager (LPM) Jeremy Fong 3 Licensing Program Analyst (LPA) Alicia Delmundo 4. Jene Snipes/Licensee 5. Ferdinand Gutierrez/Administrator 6. Dr Nandeesh Veerappa Deficiency is cited from Title 22 California Code of Regulations for administrator qualification. Additional civil penalty is issued on this day for failure to submit proof of corrections by plan of correction due date for $3M liabity insurance coverage (H&S Code 1569.605). This deficiency was cited on 7/27/23. A POC visit was conducted on 8/11/23 for failure to timely correct and with civil penalty will continue until corrected. CP = $100.00/day x 20 days (8/12/23 to 8/31/23) = $2,000.00 Deficiency and plan of correction were discussed. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 31, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 14, 2023

87405 Administrator - Qualifications and Duties: (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the ... ...premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. -This requirement is not met as evidenced by: -Administrator failed to demonstrate ....the state’s words, verbatim · CDSS document, Aug 31, 2023

Plan of correction: Administrator to take the following training from Department's vendors: 1. Dementia Care - 8 hours 2. Criminal Record - 2 hours 3. Medication Administration - 8 hours 4. Administration including but not limited to hiring practices, record keeeping. staffing and maintenance - 8 hours Proof to be submiitedby 9/14/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Sep 14, 2023

CONTINUATION: ability to comply with the Regulations as evidenced by multiple citations, civil penalties, issues such as physical plant, staffing, training, records keeping and failure to correct timely.the state’s words, verbatim · CDSS document, Aug 31, 2023

Type of visit: POC

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit, and granted entry by Maria Manjarez, staff. LPA called and spoke over the phone with Ferdinand Gutierrez, administrator, and informed the reason for visit. Administrator arrived after about 15 minutes. On 7/18/23, LPA Delmundo issued citations for the following deficiencies with POCs to be submitted by 8/01/23. Administrator submitted the POCs either after the deadline. failed to submit and/or POCs are incomplete. Civil penalties are assessed on this day, 8/11/23. 1. Deficiency section 87458(b)(5) - LIC602A Physician's Report was submitted on 8/10/23. Civil penalty = $100.00/day x 9 days (from 8/02/23 to 8/10/23)= $900.00 2. Deficiency section 87465(f)(1) - LIC9020 Register of Facility Clients/Residents has not been submitted. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 3. Deficiency section 87303(i) - proof of purchase of signal system or call button, and picture not submitted up to this day, 8/11/23. Facility does not have working call buttons as of this day, 8/11/23. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected. 4. Deficiency section 1569.695(c) - proof that disaster drills is conducted has not been submitted, Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected. 5. Deficiency section 1569.625(b)(2) - copies of staff training submitted; however, the 8 hours required annual training was not satisfied. Administrator submitted only 2 hours training and no proof of 4 hours required postural support, restricted health conditions and hospice care training. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected. .....continued on 809C 6. Deficiency section 87411(a) - administrator submitted the LIC500 Personnel Report on 8/10/23; however, it is incorrect and still shows insufficient staff coverage. LPA responded to the administrator, and on this day, 8/11/23, LPA discussed the corrections needed. Copy of corrected LIC500 provided by administrator on this day. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 7. Deficiency section 87506(a) - administrator submitted copies of LIC625 Appraisal/Needs and Services Plan and LIC602A on 8//10/23. On this day, 8/11/23, LPA reviewed residents (R4 and R6) files and observed R4's updated LIC602A is still not on the file. Administrator put the LIC602A on R4's file. Civil penalty = $100.00/day x 9 days (from 8/02/23 to 8/10/23) = $900.00 8. Deficiency section 87307(a)(3) - administrator has not submitted proof that bathrooms has paper towels in paper towel holders. On this day, 8/11/23, LPA inspected the bathrooms and observed no paper towels. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected. On 7/27/23, LPA Delmundo issued citation for deficiency section 1569.605 with POC to submit proof of $3M liability insurance coverage by 8/10/23. Administrator has not submitted the POC up to this date, 8/11/23. Civil penalty = $100.00/day x 1 day (8/11/23) = $100.00 and will continue until corrected. Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction forms, and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 11, 2023

Allegation investigated: -Staff did not adequately supervise resident (R1) while in care. -Staff do not maintain records regarding resident (R1) in care.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Ferdinand Gutierrez, administrator, and informed the reason for visit, Allegation: Staff did not adequately supervise resident (R1) while in care. It was alleged that R1 had been missing for over 12 hours and no staff realized R1 was gone until the next morning. On 6/28/23 and 7/14/23, LPA interviewed staff (S1, S2, S3, S4 and administrator) who all stated R1 has AWOL behavior, The first time R1 went out of the facility, staff followed R1 and redirected back to the facility, R1 went AWOL again and unnoticed on June 22, 2023 and June 26. 2023. One of the staff stated R1 has gone missing on the night of June 25, 2023 and noticed R1 was missing the following day in the morning of June 26, 2023. Substantiated Staff filed missing person report to local law enforcement. Police reports confirmed R1 AWOLed on the said dates. Based on information gathered, the preponderance of evidence has been met, therefore the allegation of 'staff did not adequately supervise resident (R1) while in care' is closed as substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Allegation: Staff do not maintain records regarding resident (R1) in care. It was alleged that when law enforcement responded and went to the facility, the staff were not able to provide information for R1. All staff interviewed stated R1 does not have record at the facility. During the 10-day initial visit on June 28, 2023, LPA asked the administrator for R1's file and administrator stated R1 has no record. Based on information obtained, the preponderance of evidence has been met, therefore the allegation of 'staff do not maintain records regarding resident (R1) in care' is substantiated. Deficiency section 87506(a) was cited during annual inspection on July 18, 2023 with proof of correction to be submitted by 8/01/23. Deficiencies, plan and proof of corrections were discussed with the administrator. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 27, 2023 · control 15-AS-20230626143338

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.312(a) · Plan of correction due date: Jul 28, 2023

§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 is not met as evidenced by: -Based on interviews and review of police reports, the licensee did not comply with the section above for R1 who was able to AWOL which posed immediate safety risk to person in care.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator to do the following, and submit proof by 7/28/23: 1. Complete Appraisal/Needs and Services Plan. 2. In-service the staff.

Type of visit: Case Management - Deficiencies

On this day, July 27, 2023 at 12:30 p.m, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit. LPA was granted entry by staff, Rosa Maria Munoz. LPA called and spoke over the phone with Ferdinand Ferdie' Gutierrez, administrator, and informed the purpose of visit. Administrator arrived after several minutes. The other 2 staff. Maria Manjarez and Beatriz Munoz, arrived at around 1:00 pm. On July 6, 2023, LPAs Delmundo and Fontanilla observed Medication Administration Record for May 2023 showed Insulin was administered by staff but not for June and July 2023; however, this medication was last filled 6/21/23. This medication is for resident (R4) and LPAs interviewed staff (S3) who stated she administered the insulin in May and didn't do the administration in June and July. However, during today's visit. July 27, 2023, in the presence of the administrator S3 stated she didn't administer the insulin but signed the May 2023 MAR. Also on July 6, 2023, LPAs requested for the following documents to be submitted by July 20,2023: 1. LIC9282 Infection Control Plan - this document has not been submitted as of this day. 2. Proof of $3M liability insurance coverage - administrator showed to LPA the insurance coverage for Manor Manor facility; however, the licensee on the document is not that of Mori Manor, LLC which is the current licensee. On this day, July 27, 2023, LPA observed staff (S1) working at the facility, and S1 is not fingerprint cleared and associated to this facility. LPA verified, and S1 and adminstrator stated S1 started working July 24, 2023. Staff Schedule effective July 24, 2023 also showed S2 on the schedule. LIC500 Personnel Report dated July 18, 2023 showed S2 was emplored 9/2022. Guardian Portal showed S2 has fingerprint clearance but not associated to this facility. ......continued on 809C Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $400.00 civil penalty is assessed for section 87355(e)(1) for S1 who is not fingerprint cleared, and $250.00 for repeat violation of section 87355(e)(2) within 12 month period. Deficiencies, plan and proof of corrections and civil penalties were discussed with the administrator. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and LIC421FC Civil Penalty Assessments, and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 27, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jul 28, 2023

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required.... ... by the Department -This requirement is not met as evidenced by: -Based on observation, interview and Guardian Portal check, the licensee did not comply with section above for having S1 work without fingerprint clearance. This is a repeat violation.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator have the staff go for fingerprinting while LPA is still at the facility. Administrator to read the Regulation and will not allow the staff to work until claared and associated. Proof to be submitted by 7/28/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(e) · Plan of correction due date: Jul 28, 2023

87465 Incidental Medical and Dental Care: (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file..... -This requirement is not met as evidenced by: -Based on observation and interview, the licensee did not comply with the section above for R4 who has insulin but no file and/or record of doctor's order. Insulin was not administered and facility does not have discontinued order. It's not clear it the med is still needed.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator to check with the resident's physician if the medication is still needed. If still needed, to have a licensed professional administer; otherwise, obtain a discontinued order. Proof to be submitted by 7/28/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(2) · Plan of correction due date: Aug 10, 2023

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance ... This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for S2 who is not associated to this facility. This is a repeat violation within 12 month period. First violation was issued on 7/18/23.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Corrected. Administrator submitted the LIC9182 on this day. A $250.00 is assessed on this day,

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(a) · Plan of correction due date: Aug 10, 2023

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. -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for staff affixing initial on R4's MAR but the medication was not administered.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator to in-service the staff, and submit copy of traing topic with attendees signatures by 8/10/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(c) · Plan of correction due date: Aug 10, 2023

87470 Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. -This requirement in not met as evidenced by: -Based on interview and records review, the licensee did not comply with the section above for not having an Infection Control Plan which poses potentiall health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator to developed a plan and submit copy by 8/10/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR1569.605 · Plan of correction due date: Aug 10, 2023

§1569.605 Liability insurance; coverage requirements: On and after July 1, 2015, all residential care facilities for the elderly, .... shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate..... -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section for not having insurance coverage under licensee's name.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Licensee to obtain insurance coverage, and submit proof by 8/10/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569,69(b) · Plan of correction due date: Aug 10, 2023

§1569.69 Employees assisting residents with self-administration of medication; training requirements (b) Each employee who received training and passed the examination... and who continues to assist with the self-administration of medicines, shall also complete four hours.. of in-service training on medication-related issues in each succeeding 12-month period. -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section for S3 not having the required hours of annual medication training,the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator to have the staff trained and submit proof by 8/10/23.

Type of visit: POC

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit, and met with Ferdinand Gutierrez, administrator. LPA informed the purpose of visit. On 7/06/23, LPAs Delmundo and Fontanilla initiated an annual required inspection and issued citation for deficiency section 87309(a) with POC to be submitted by 7/07/23. Administrator submitted the POC only 7/11/23. A $400.00 civil penalty is assessed on this day, 7/27/23, for $100.00/day from 7/08/223 to 7/11/23. On 7/18/23, LPA Delmundo issued citation for deficiency section 87355(e)(1) for staff who was not fingerprinted with POC to be submitted by 7/19/23. Administrator submitted the POC only on this day, July 27, 2023. A $800.00 civil penalty is assessed for $100.00/day from 7/20/23 to 7/27/23. Deficiency section 1569.153(a) was cited for Theft and Loss Policy not posted with POC to be submitted by 8/01/23. On this day, LPA observed the Policy is posted. Exit interview conducted. Appeal Right, LIC421FCs Civil Penalties and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 27, 2023

Type of visit: POC

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit, and met with Ferdinand Gutierrez, administrator. LPA informed the reason for visit. On July 6, 2023, LPAs Delmundo and Fontanilla started the annual required inspection. Deficiency section 87204(a) was cited for having 2 non-ambulatory residents in ambulatory only rooms. Administrator stated he'll have the residents moved to rooms with fire clearance for non-ambulatory with proof of correction (POC) to be submitted by July 7, 2023. A civil penalty was assessed on July 6, 2023 which will continue until corrected. As of this day, July 18. 2023, administrator has not submitted the POC, LPA Delmundo conducted inspection and interviewed staff (S1) and administrator who both stated that resident (R3) was only moved on Tuesday, July 11, 2023. An additional civil penalty of $400.00 is assessed on this day for $100.00/day from July 8, 2023 to July 11, 2023 and was discussed with the administrator. Administrator has to leave, and authorized JulyFrancia Yambao, staff, to sign and received this report. Copy of this report, Appeal Rights and LIC421FC Civil Penalty Assessment provided.the state’s words, verbatim · CDSS document, Jul 18, 2023

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on July 6, 2023. LPA was granted entry by Maria Manjare, staff. Ferdinand Gutierrez, administrator, arrived after several minutes. LPA informed the reason for visit. LPA also met with other staff, JulyFrancia Yambao. On July 6, 2023, LPAs Delmundo and Fontanilla observed the following but LPAs were not able to issue citations due to technical difficulties/issues: -facility's Theft and Loss policy not posted and no Complaint poster. -broken window blinds and protruding cable wires in room # 2. -no paper towel in dispensers in 2 bathrooms. According to staff, supply of paper towel for the type of dispensers ran out -at 12:02 pm, CALRes incontinence since and Pine Sol cleaning agent in the bathrooms. -pieces of carpet, wood, metal, rolled carpet, piece of glass, fitted bedsheet in the side yard. -mattress, window screen, hoyer lift, pieces wood, bedsheet, grinder in the backyard. --residents' medications in the refrigerator. Medication Administration Record for May 2023 showed Insulin was administered by staff but not for June and July 2023; however, this medication was last filled 6/21/23. -resident (R4) does not have records in the facility -staff (S1) is not fingerprint cleared and associated to this facility. -staff (S2 and S3) First Aid certificates on file expired 2018 and 2021. -facility does not have file drill records. LPAs interviewed S3 who stated they don't do fire drill. ......continued on 809C (page 2) Page 2 -On 7/06/23, LPA Fontanilla observed staff (S1) does not have First Aid/CPR training on file. S4 and administrator's First Aid/CPR certificates expired. -LPAs Delmundo and Fontanilla observed cameras in the living room. kitchen and family room. LPAs checked with staff who has access to the camera and observed the cameras also capture audio. The following additional deficiencies were also observed: -S1, S2, S3 and S4 do not have the 20 hours required annual training. -S3 administers medications but does not have required 8 hours annual training. Last training on file was dated 2016. -Staff (S6) who came to work at 5:00 pm 7/06/23 and on this day (7/18/23) not associated to this facility. -Resident's (R2) bed has half bed rails but no doctor's order on file. -Resident (R6) also does not have records. -Resident (R5) has no TB test record on file. -Residents do not have call buttons. -Three residents need 2 person assist in transferring which LPA confirmed with 2 staff and administrator; however, there are only 2 staff scheduled at the time leaving other residents with no staff available to assist. -Resident's (R7) LIC602A PhysIcian's Report indicated ambulatory; however, R7 needs assistance in transferring which LPA confirmed with the staff, administrator and family member. -No LIC9020 Register of Facility Clients/Residents Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500 civil penalty is assessed for section 87355(e)(1), .and $250.00 for repeat violation of section 87303(a) within 12 month period. Deficiencies, plan and proof of corrections and civil penalties were discussed with the administrator. Administrator has to leave and authorized JulyFrancia Yambao to sign and receive this report. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and IC421FC Civil Penalty Assessments provided.the state’s words, verbatim · CDSS document, Jul 18, 2023

Allegation investigated: Staff do not ensure medication cabinet is locked. Staff do not ensure facility is free from pests. Staff left a resident in bed for an extended period of time. Staff do not ensure resident common areas are free from hazards. Staff do not ensure hazardous chemicals are inaccessible to residents.

On 7/17/23 at 12:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegations above and deliver findings. LPA met with Ferdinand Gutierrez, Administrator and explained the purpose of the visit. During the visit LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. Staff do not ensure medication cabinet is locked. LPA observed the medications were locked in a closet in the kitchen. Staff do not ensure facility is free from pests. LPA observed a few flies in the facility and no screen on a kitchen window. LPA advised ADM to purchase insect spray that is safe for indoor use. Report continues on LIC9099C Unsubstantiated Report continues from LIC9099 Staff left a resident in bed for an extended period of time. LPA interviewed ADM who stated all the non-ambulatory residents are taken out of bed to be toileted daily and as needed. LPA interviewed R1 and R2 who were both in their beds in their rooms. R1 stated she gets up every day to do her leg exercises and eat her meals. R1 also stated that her roommate (R4 who was sleeping) also gets up everyday and socializes with the other residents. R2 stated he wants to get out of bed more but did not blame the staff. R2’s personal choice is to stay in bed. LPA could not interview R3 as he was sleeping. LPA interviewed S1 and S2 who both stated the they get the residents up every day to eat their meals, shower and socialize. S1 and S2 also stated that it is hard to get R2 out of bed because he likes to stay in bed. Staff do not ensure resident common areas are free from hazards. LPA observed all common areas to be free from hazards. Staff do not ensure hazardous chemicals are inaccessible to residents. LPA observed that the cleaning supplies and laundry detergent were both locked and inaccessible to residents. LPA investigated the complaints alleging staff do not ensure medication cabinet is locked, staff do not ensure facility is free from pests, staff left a resident in bed for an extended period of time, staff do not ensure resident common areas are free from hazards and staff do not ensure hazardous chemicals are inaccessible to residents. We have found that the complaints are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 17, 2023 · control 15-AS-20230707155046

Type of visit: Office

An Informal Conference was held on this day, July 13, 2023, via video conference. The purpose of this conference was to discuss non-compliance issues. The informal conference process was explained to the licensee, administrator, applicant for new license. Present at the meeting were: 1. Regional Manager (RM) Isaac Taggart 2. Licensing Program Manager (LPM) Jeremy Fong 3. Licensing Program Analyst (LPA) Alicia Delmundo 4. Jene Levine Snipes - Licensee 5. Ferdinand Gutierrez - Administrator 6. Dr. Nandeesh Veerappa - applicant for new license Issues discussed during the meeting: - Lost of control of property -Conditional permit -On-going facility issues and concerns .....continued on 809C At the conclusion of this informal conference, licensee was informed of the following: 1. While application is still to be submitted, licensee is fully responsible for care and supervision of residents. 2. Conditional Use Permit has to be submitted to the Department. Exit interview conducted and copy of this report provided to licensee and administrator via e-mail.the state’s words, verbatim · CDSS document, Jul 13, 2023

Type of visit: Required - 1 Year

On this day, July 7, 2023 at 11:25 a.m, Licensing Program Analysts (LPAs) A. Delmundo and L. Fontanilla arrived unannounced to conduct an annual required inspection. LPA met with staff Maria Manjarez and Blesilda 'Blesie' Yamat, and informed the reason for visit. LPAs also met with Mauricio David. LPA Delmundo spoke over the phone with Ferdinand Ferdie' Gutierrez, administrator, who can not come to the facility, and gave permission to have Maria Manjarez to sign and receive this report. Facility has not submitted an LIC9282 Infection Control Plan. LPAs inspected the facility inside and out with Mauricio David and Maria Manjarez including but not limited to common areas, bedrooms, bathrooms, living room, kitchen, dining area, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced March 15, 2023. Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the bathrooms was tested and measured at 107.6 degrees Fahrenheit. LPAs reviewed 5 residents and 5 staff files, and interviewed 3 staff and 2 residents. Facility does not handle residents' cash resources. LPAs observed the following: -at 11:45 am, faciliy's Theft and Loss policy not posted and no Complaint poster. -at 11:59 am, broken window blinds and protruding cable wires in room # 2. -at 12:01 and 12:19 pm. no paper towel in dispensers in 2 bathrooms. According to staff, supply of paper towel for the type of dispensers ran out .......continued on 809C (page 2) Page 2 -at 12:02 pm, CALRes incontinence since and Pine Sol cleaning agent in the bathrooms. -at 12:23 pm, pieces of carpet, wood, metal, rolled carpet, piece of glass, fitted bedsheet in the side yard. -at 12:33 pm, rake, mattress, window screen, hoyer lift, pieces wood, bedsheet, grinder in the backyard. --at 12.43 pm, residents' medications in the refrigerator. Medication Administration Record for May 2023 showed Insulin was administered by staff but not for June and July 2023; however, this medication was last filled 6/21/23. -residents (R1 and R3) who use cane and wheelchair respectively are in the rooms not fire cleared for non-ambulatory. -At 3:00 pm, resident (R4) does not have records in the facility -staff (S1) is not fingerprint cleared and associated to this facility. -staff (S2 and S3) First Aid certificates on file expired 2018 and 2021. -facility does not have file drill records. LPAs interviewed S3 who stated they don't do fire drill. Licensee (Mori Manor, LLC) lost control of property when the property was sold, and licensee failed to inform Community Care Licensing. Administrator to submit the following updated documents by July 20, 2023: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. LIC9282 Infection Control Plan 4. Proof of $3M liability insurance coverage ....continued on 809C (page 3) Page 3 Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500 and $250.00 civil penalties deficiency section #s 87204(b) and 87309(a) were assessed and will continue until corrected. Deficiencies, plan and proof of corrections and civil penalties were discussed with the administrator over the phone.. Due to technical difficulties/issues, LPA to come back to issue citations for the rest of deficiencies observed and continue inspection. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and LIC421FC Civil Penalty Assessments provided to Maria Manjarez.the state’s words, verbatim · CDSS document, Jul 6, 2023

The state marks this report as 16 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff uninstalled smoke detector from resident's room.

Licensing Program Analyst (LPA) Delmundo arrived unannouced to investigate the above allegation. LPA was granter entry by Maria Manjarez, staff. Ferdinad Gutierrez, administrator, arrived after several minutes, LPA informed reason for visit. LPA conducted inspection with Ferdinand Gutierrez and conducted interviews. It was alleged that the smoke detector in one of the resident's room was beeping continously and was observed removed from the ceiling, LPA interviiwed the administrator who confirmed the detector was beeping and was removed about 2 weeks ago, LPA conducted inspection, and observed smoke detectors were removed from the ceiling in room #'s 1, 2, 3, 5 and 6, and family room. ....continued on 9099C Substantiated Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 immediate civil penalty is assessed for fire safety violation and will continue for $100/day until corrected. Deficiency, plan and proof of correction, and civil penalty were discussed with administrator. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jun 28, 2023 · control 15-AS-20230626085047

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jun 29, 2023

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. -This requirement is not met as evidenced byL -Based on observation and interview, the licensee did not comply with the section above for removing the smoke detectors in 5 residents rooms and family room. Civil penalty is assessed.the state’s words, verbatim · CDSS document, Jun 28, 2023

Plan of correction: Administrator stated he'll have smoke detectors installed, Pictures to be submitted by 6/29/23. A $500.00 civil penalty is assessed today.

Type of visit: Case Management - Deficiencies

While at the facility investigating two complaints (Control #'s 15-AS-20230626085047 and 15-AS-20230626143338), Licensing Program Analyst (LPA) Delmundo observed the following while conducting inspection with Ferdinand Gutierrez, administrator: 1. Front entrance door and 2 of the residents' rooms do not have auditory signals. The exit doors in the kitchen and family room's auditory signals broken. Resident (R1) was able to AWOL unnoticed by the staff. 2. Strong smell of urine. The administrator stated that resident (R2) who has dementia and incontinent is refusing care. 3. Used mattress, big piece of rolled carpet in the front yard, and pieces carpet in the side yard. 4. Grass cutter, shovel and rake in unlocked storage in the side yard. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of correction by plan of correction due dates, and any repeat violation within 12 month period may result in additional civil penalties. Deficiencies plan and proof of correction were discussed with administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jun 28, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Jun 29, 2023

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. -This requirement is not met as evidenced by: -Based of observation, the licensee did not comply with the section above, for entrance and exit doors not having auditory signals which posed immediate risk to persons in care,the state’s words, verbatim · CDSS document, Jun 28, 2023

Plan of correction: Administrator stated will have auditory signals installed. Pictures to be submitted by 6/29/23,

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Jun 29, 2023

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. -This requirement is not met as evidenced by -Based on observation, the licensee did not comply with the section for having the storage in the side yard not locked which poses immediate safety risks to persons in care,the state’s words, verbatim · CDSS document, Jun 28, 2023

Plan of correction: Administrator locked the storage, In addition, administrator to do in-service training, and submit copy of training topic with attendees signatures by 6/29/23,

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 12, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sthe safety and well-being of residents, employees and visitors.anitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety -This requirement is not met as evidenced by: -Based o observation, the licensee did not comply with the section above for the soiled mattress & carpet in the yard which pose potential risks to person in care,the state’s words, verbatim · CDSS document, Jun 28, 2023

Plan of correction: Adminstrator to have the yard cleaned, and, submit pictures by 7/12/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87625(b)(3) · Plan of correction due date: Jul 12, 2023

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section for facility having a strong smell of urine which poses personal rights risk to persons in care,the state’s words, verbatim · CDSS document, Jun 28, 2023

Plan of correction: Administrator stated will find placement for the resident. Proof to be submitted by 7/12/23. Staff to continue to encourage the resident to be assisted in incontinence care while placement is pending.

Allegation investigated: Resident not given medications Resident not fed Staff not providing enough water to resident Resident not repositioned Resident's chuck pad and clothing not changed

On 06/15/23 at 12:45 PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator. Allegation: Resident not given medications Investigation Finding: Unsubstantiated During investigation, staff confirmed with LPA that resident (R1) refused to take all her medications from 12/06/21 until 04/09/23. Review of resident (R1) centrally stored medication logs and medication administration records show R1’s documented medication administration record (MARs) refusals. Review of other residents (R2, R3, R4) MARs show residents received assistance daily from staff in taking their prescribed medications Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident is not given medications is unsubstantiated. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Resident not fed Investigation Finding: Unsubstantiated During investigation, staff (S1) confirmed with LPA that resident (R1) refuses to eat hot food prepared for breakfast, lunch and dinner. S1 stated R1 only wants to eat cereal and drink water. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident is not fed is unsubstantiated. Allegation: Staff not providing enough water to resident Investigation Finding: Unsubstantiated During investigation, staff (S1) stated that they provide resident (R1) with water daily. R1’s constant refusal to take her medications and drink enough water has led her to be sent to the hospital several times for constipation and bowel impaction. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff is not providing enough water to resident is unsubstantiated. Allegation: Resident not repositioned Investigation Finding: Unsubstantiated During investigation, staff (S1) confirmed with LPA that she provided care and supervision to resident (R1) at the facility. S1 stated she cleaned R1, changed her chuck pad daily and repositioned her when allowed by R1. ADM confirmed with LPA that R1 constantly refused to be cleaned, eat food prepared for residents and take her medications. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident is not repositioned is unsubstantiated. Allegation: Resident’s chuck pad and clothing not changed Investigation Finding: Unsubstantiated During investigation, staff (ADM, S1) confirmed with LPA that resident (R1) constantly refused to get cleaned and chuck pads changed. S1 stated she changes R1’s chuck pads and clean her daily when allowed by R1. However, R1 doesn’t want to be touched and told S1 that her bed was eating her private parts up. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident’s chuck pad and clothing is not changed is unsubstantiated. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 15, 2023 · control 15-AS-20230411143331

Type of visit: Case Management - Other

On 06/15/23, while at the facility for another reason, Licensing Program Analyst (LPA) observed resident’s (R1) written documents (pre-appraisal report, admission agreement, physician’s report, needs & services plan, ID and emergency information) were not available for inspection at the facility. ADM stated R1 called 911 herself on 4/09/23 and was taken to ER hospital by ambulance. Staff gave paramedics R1's folder of documents containing her admission agreement, pre-appraisal/ appraisal reports, physician's report, incident reports, needs and services plan. ADM stated he was not able to locate R1’s missing folder at the hospital. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 15, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jun 30, 2023

The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement was not met as evidenced by missing resident’s written records at the facility which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: By POC due date, administrator agreed to submit to CCL completed in-service staff retraining on proper administration of residents' records ensuring all residents' files are readily available for licensing and other agencies' review and inspections.

Allegation investigated: Facility staff serving expired food

On 1/26/23 at 9:00AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced complaint visit. LPA meet with administrator Ferdinand V. Gutierrez and explained the purpose of the visit with administrator. Allegation: Facility staff serving expired food Investigation Finding: SUBSTANTIATED During investigation, LPA toured the facility kitchen. LPA observed servals expired can goods and pre-made cupcake boxes( best used by 12/31/22, creamy peanut butter 7/30/22, and cocktail sauce for seafood 9/30/22) inside the pantry located in the kitchen. LPA took photos of expired food items during visit. Report continue on LIC 9099C... Substantiated Based on LPA’s observations the preponderance of evidence standard has been met, therefore the above allegation(s) were found to be SUBSTANTIATED. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. Allegation: Residents using bedroom as a restroom Investigation Finding: UNSUBSTANTIATED During investigation, LPA toured the facility living room, and inside residents’ rooms. LPA interviewed 6 residents 6 out of 6 states that no one here using the bedroom as a restroom; only those that are on bed written are using the restroom inside the room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report is provided.the state’s words, verbatim · CDSS document, Jan 26, 2023 · control 15-AS-20230118161740

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(28) · Plan of correction due date: Jan 27, 2023

General Food Service Requirements - All foods shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Based on observation, there were multiple expired foods in the in the pantry, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2023

Plan of correction: Licensee will ensure all expired foods are disposed, and submit certification of compliance to CCL by POC date.

Type of visit: POC

On 4/28/22 approximately 9:25am, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a proof of correction (POC) visit for the deficiencies cited on 4/14/2022. LPAs met with caregiver Gladys Salguero and spoke with Administrator, Ferdinand Gutierrez on the phone, and explained the purpose of the visit. Administrator had submitted resident's Needs & Service Plan to CCL via email at 3:24pm on 4/22/22, however had LPA's email in error so LPA didn't received it. Administrator resubmitted it to LPA during visit. LPA obtained resident's note of changing in condition during visit. Administrator forgot to retrain staff for regulation, and admitted that the training would be provided and submitted to CCL today, 4/28/22, otherwise civil penalty will be issued. No deficiencies are being cited on this date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 28, 2022

Type of visit: POC

On 4/19/22 approximately 1:50pm, Licensing Program Analysts (LPAs) C. Lin and K. Nguyen arrived unannounced to conduct a proof of correction (POC) visit for the deficiencies cited on 4/14/2022. LPAs met with Administrator, Ferdinand Gutierrez and explained the purpose of the visit. Administrator admitted that he has not submitted POC for 87705(f)(2). A civil penalty has been assessed from 4/14/2022 to 4/19/2022 at $100 x 6 = $600. LPAs printed out regulations 87705 for Administrator to review and submit correct documents. Plan and proof of correction was discussed with Administrator. Civil Penalties will continue to be assessed daily until corrected. No deficiencies are being cited on this date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 19, 2022

Type of visit: Case Management - Other

On 4/12/22 at 1:05pm, Licensing Program Analyst (LPA) C Lin arrived unannounced to conduct a case management visit as a result of receiving a self-report dated on 4/7/2022 to indicate a resident developed wound in stage 3 while in care. LPA met with the caregiver Gladys Salguero and explained the purpose of the visit. Administrator Ferdinand Gutierrez was unavailable and authorized the caregiver on the phone to sign on this report. At 1:10pm, LPA toured the facility and observed that the laundry room door was let opened with a long brown wood stick on purpose, laundry detergent was observed inside the laundry room. Staff stated that the dryer was missing a hose of exhausting heat when it was installed in February 2022, when the door was closed steam would be filled up the laundry room. Therefore, staff let the door open for about 2 hours every time when they did the laundry. 1 resident with Dementia and 1 resident with Cognitive issue were observed walking inside facility when the laundry room door was opened. Staff locked laundry room door during visit. At 1:30pm LPA reviewed the file of resident who developed pressure injury while in care. Staff stated that resident was sent to emergency room in time manner when wound was noticed, home health nurse was ordered by resident's physician when discharging from hospital. LPA spoke with home health nurse and hospice nurse from the agency Health Flex to be confirmed that resident's wound has been monitored and in care. However, facility was unable to provide document of resident's changing condition and update appraisal/care plan. LPA spoke with Administrator on the phone, Administrator admitted that resident's care plan has not been updated. The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with caregiver, LIC809D, Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 12, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Apr 13, 2022

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (2) ...alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by: Based on observation, interview and records review, the licensee did not comply with the section cited above. LPA observed unlocked detergent in the laundry room which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Staff locked the laundry room during visit. Administrator will retrain staff for regulations and submitted training agenda and sign-in sheet to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Apr 22, 2022

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.... This requirement was not met as evidenced by: Based on observation, interview and records review, the licensee did not comply with the section cited above. LPA observed appraisal/care plan has not been updated due to changing in condition.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Administrator will retrain staff for regulations and submitted training agenda and sign-in sheet to CCL In addition, facility will update notes of changing condition and appraisal/care plan for resident and submit copies to CCL by the POC due day.

Type of visit: Case Management - Other

On 8/13/2021 at 2:55pm, Licensing Program Analyst (LPA) L. Francisco arrived to conduct a Component III presentation. LPA met with Administrator, Ferdinand Gutierrez and explained the purpose of the visit. LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed the Administrator gained knowledge about running and maintaining the facility in accordance with regulations. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 13, 2021