Orange Grove Senior Living

Type of visit: POC

Licensing Program Analysts (LPA) Pang Lee arrived at the facility on 11/02/2023 at 8:05 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee met with direct care staff, Teresa Autencio and explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of corrections that was due on 10/23//2023. During today's visit, LPA Lee reviewed residents and staff files to ensure all deficiencies previously cited have been corrected. Based upon this inspection, the LPAs observed the following: I. Deficiency cited under Title 22 Regulation 87412(a) has been cleared. The Licensee complied with the terms of the POC by POC due date 10/23/2023. A POC letter was generated and provided to the licensee. 2. Deficiency cited under Title 22 Regulation 87506(a) has been cleared. The licensee complied with the terms of the POC by POC due date 10/23/2023. A POC letter was generated and provided to the licensee. An exit interview was held, and a copy of this report, LIC 809, was given to the facility at the end of the visit.the state’s words, verbatim · CDSS document, Nov 2, 2023

Type of visit: POC

Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 09/20/2023 at 9:45 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee met with administrator, Christine Torres. The current Census is 6 with 2 facility staff. LPA explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of correction that was due 09/08/2023. During today's visit, LPA Lee reviewed staff and resident files previously cited on 08/24/2023 to see if POC have been corrected. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. Based upon this inspection, LPA Lee observed the following: 1. Deficiency cited under Title 22 Regulation 87412(a) has not been cleared. The license did not complied with the terms of the POC by POC due date. A POC letter was not generated and provided to the licensee. 2. Deficiency cited under Title 22 Regulation 87506(a) has not been cleared. The license did not complied with the terms of the POC by POC due date. A POC letter was not generated and provided to the licensee. The license did not complied with the terms of the POC by POC due date. As a result of this POCl visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Sep 21, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: Oct 5, 2023

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee did not ensure 1 out of 6 facility staff files were current and up to dare, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 21, 2023

Plan of correction: licensee agrees to up date facility staff files and notify LPA Lee by POC date 09/08/2023 by 5:00 PM by end of day. Administrator stated that staff has an physical appointment to get health screening completed on 10/05/2023 at 1:50 AM. Licensee agrees to email LPA Lee at pang.lee@dss.ca.gov a copy of staff LIC 503.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Oct 5, 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: Licensee agrees to up complete and up date 5 out 6 resident files and notify LPA Lee by POC date 09/08/2023 by 5:00 PM by end of day. LPA lee gave administrator a copy of what is missing in the 6 resident's file from LIC 858 on a word document.the state’s words, verbatim · CDSS document, Sep 21, 2023

Plan of correction: Licensee agrees to up complete and up date 5 out 6 resident files and notify LPA Lee by POC date 10/05/2023 by 5:00 PM by end of day. Administrator have given resident's conservator the documents to sign.

Type of visit: Required - 1 Year

On 08/24/2023 at 8:00 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff, Teresa Autencio and her husband Geronimo, who then called administrator, Christine Torres. Administrator, Christine arrived approximately one hour later. LPA Lee explained the purpose of the visit. Administrator, Christine assisted with today’s visit. Administrator certificate # is 6042576740 and will expire on 10/23/2024. The current census is 6 with 2 facility staff. This facility is a two story building licensed to serve three (3) non-ambulatory residents and three (3) ambulatory residents. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor and clean. LPA Lee observed resident room #4 intercom box not in good repair with exposed wired. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 127.8 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Fire alarm and carbon monoxide detectors are in compliance with fire safety. LPA Lee observed one fire extinguisher in the kitchen without a service tag or a receipt of purchased on the fire extinguisher. LPA Lee also observed two fire extinguisher in the upstairs hallway. The second fire extinguisher also did not have a service tag and receipt attached to it. The third fire extinguisher service tag was dated on 09/04/2018. LPA Lee observed the facility has a has a public telephone in the common room and the facility have the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 74 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. Continued LIC 809-C LPA Lee reviewed 3 out of 3 medication administration record (MAR) and it was complete. LPA Lee observed one resident medication is not in it's original box. First aid kit was checked and is complete. LPA Lee requested residents and staff files for review. LPA Lee reviewed 6 out of 6 resident files and 6 out of 6 resident file was not complete. LPA Lee reviewed 3 out of 6 staff files and 3 out of 6 staff files were not complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents were given to LPA Lee during today's visit. (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610 Emergency Disaster Plan (5) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, LIC 9102 Technical Violation and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Aug 24, 2023

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA Martinez met with Christine Torres and explained the purpose of the visit. The purpose of the visit today, is in response to a change of Administrator and a corporation change- LIC 200 application follow up. LPA Martinez informed Christine Torres an LIC 200 application will need to be submitted to the Centralized Application Bureau (CAB), and LPA Martinez provided CAB's website and telephone number information. https://www.cdss.ca.gov/inforesources/community-care/ascp-centralized-application-units https://www.cdss.ca.gov/cdssweb/entres/forms/English/LIC200.pdf CAB Phone number: (833) 827-6084 Christine reported she is working on submitting the LIC 200 application to CAB. In addition, the following Administrator documentation will need to be submitted to CCLD: LIC 200 from licensee requesting administrator Change Board Resolution for new administrator if corporation LIC 308 Designation of Facility Responsibility LIC 501 Personal Record LIC 503 Health Screening Report LIC 500 Personnel Report Administrator Certificate An exit interview was conducted, and a copy of this report was provided to Christine.the state’s words, verbatim · CDSS document, Apr 19, 2023

Type of visit: Case Management - Other

On April 14, 2023 At :30 PM, Licensing Program Analysts (LPA) Avelina Martinez and LPA Pang Lee arrived unannounced to deliver an Order of Exclusion for a staff member. LPAs Martinez and Lee met with Theresa Autencio and explained the purpose of today's visit. LPAs Martinez and Lee were informed by Theresa Autencio, staff member named in the Order of Exclusion, Maricar Venegas no longer works at the facility. LPA Martinez also conducted a phone call with Christine Torres during today's visit. Christine Torres reported Maricar Venegas does not live at the facility, and does not visit the facility. LPAs Martinez and Lee provided the Theresa Autencio with a copy of the Order and explained that Maricar Venegas is not allowed in the facility effective immediately. Exit interview was held, and a copy of this report and Immediate Exclusion letter were provided to the facility.the state’s words, verbatim · CDSS document, Apr 14, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection on 08/04/2021. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations. The LPA toured the facility with Christine Torres on 08/24/2021 at 10:50 AM. Administrator holds current certificate. The facility is licensed for six resident (three ambulatory and three non-ambulatory) There are currently 5 residents who reside at this facility. The facility has one main entry screening point. The facility conducts disinfecting cleaning daily, and the facility has a 30 day supply of PPE. The facility has covid-19 postings throughout the facility. The facility furniture is spaced 6 feet apart. The facility was sanitary and clean. Smoke and Carbon detectors were in good repair. LPA Martinez reviewed one employee file and one resident file. The facility files were up to date. Moreover, resident bedrooms and bathrooms were sanitary. The facility has a seven day supply of food, and all toxins are locked. The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. Exit interview held and a report given at the end of the visit.the state’s words, verbatim · CDSS document, Aug 4, 2022

Allegation investigated: Facility is unsafe Facility is unsanitary Food is not prepared in a healthful manner Staff did not assist resident with their basic laundry services Staff speaks inappropriately to residents in care

On 06-02-2022 at 12:30 PM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to deliver complaint findings. LPA Martinez met with Theresa Autencio and explained the purpose of today's visit. Throughout the course of the investigation, interviews and file reviews were conducted. LPA interviewed four out of 6 residents. Two residents did not want to be interviewed. Four residents reported feeling safe in the facility, and reported the facility was clean and sanitary. LPA Martinez inspected bathrooms, and there were no rug hazards. There is also a designated area for smoking, and residents are supervised when smoking. Additionally, four residents reported the food was good and prepared in a healthful manner. It was also reported by residents that the facility staff was washing their clothes. Moreover, residents reported staff treat them well and have no issues. Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was given to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 2, 2022 · control 27-AS-20220511153533

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

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection on 08/24/2021. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations. The LPA toured the facility with Christine Torres on 08/24/2021 at 2:36 PM. The facility has submitted a mitigation plan to CCLD. The mitigation plan has been approved by CCLD. The facility has one central entry point for universal entry screening. All visitors, staff, and essential workers are screened for Covid-19 symptoms. Moreover, hand hygiene postings are posted in bathrooms. The facility has hand sanitizer dispensers throughout the facility. The facility conducts hourly disinfection cleaning. Facility common areas are furnished and furniture is spaced 6 feet apart. The facility smoke and carbon detectors are in good repair. The facility exterior patio is clear of derbies. The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. Exit interview held and a report given at the end of the visit.the state’s words, verbatim · CDSS document, Aug 24, 2021