Queen of the Angels Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with caregiver Maryanne Vergara and Joel Basilio assisted with the visit. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is licensed to serve elderly residents age 60 and above. The fire clearance approved for two (2) ambulatory and four (4) non-ambulatory residents age 60 and above. Approved to accept or retain resident one (1) on hospice. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1.infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting once a day and more often for high touched surfaces area. Facility has sufficient PPE supplies and has an Infection Control Plan. 2. Operational Requirement: The facility has a dementia care plan to accept or retain residents with dementia. There is currently one resident is on hospice and bedridden which is under the fire clearance requirement. The facility has the sufficient amount for liability insurance covering injury to residents and guests. 3. Physical Plant and Environmental Safety: The facility is a single story house and located in residential neighborhood area. The facility includes family room, dining room, kitchen, living room, five residents bedrooms, one live in staff bedroom, three bathrooms, laundry room, staff office and an isle. All the passageway and drive way and patio are free of obstruction. The facility has a pool in the backyard but they were covered by the fence and they are inaccessible to residents. Bedroom#1 - #4 has one bed, one night stand, one drawer, one chair, required beddings and sufficient lighting and closet space. Bedroom#5 has two beds, two drawers, two night stands, two chairs, required beddings and sufficient lighting and closet space. The bathrooms are clean, sanitary and in an workable condition. All the bathrooms also have grab bar and non-skid mat. The hot water water temperature in bathroom#1 and #2 are tested between 113.1 and 118.5 degrees F and they are within the Title 22 regulation. All the kitchen appliances are working properly. All the sharp knives and utensils are stored and locked in the kitchen drawer next to the sink. All the cleaning supplies and chemicals are stored and locked in the cabinet in the laundry room. The facility has ample supply of personal hygiene products and stored in the bathroom#1, LPA inspected the carbon monoxide detectors and smoke detectors and they are interconnected and they are operable. 4. Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Staff all have updated First Aid and CPR certificate except the administrator. 5. Personnel Records/Staff Training: All staff files are maintained in the facility except the administrator file. The administrator is Terry McGee but due to administrator files was not maintained in the facility and LPA did not know when the administrator certificate will be expired. 6. Resident's Record/Incident Reports: All residents files are stored and maintained in the facility in the medication cabinet. The resident files do not have a complete and current record. Resident#1 is missing Resident appraisal, admission agreement. Resident#2 is missing pre-appraisal, resident appraisal, and updated physician report. Resident#3 is missing physician report and resident appraisal. Resident#4 is missing resident appraisal and physician report. Resident#5 is missing admission agreement, physician report and resident appraisal. 7. Resident's Right and Information: The facility has all the posted include resident's personal right and complaint poster..etc and its located on the wall near the entrance. The facility also has internet service device for residents to use. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Services: There are sufficient food supplies of 2-days perishable and a week of non-perishable items. The food are properly stored in the refrigerator. 10. Incidental Medical and Dental: All residents medication are centrally stored and locked in the hallway medication cabinet. LPA inspected all resident medication and they all seemed accurate and updated. 11. Disaster Preparedness: The facility does not have an updated emergency disaster plan but facility does have two alternative shelter location and the facility does not have any record of the last fire or earthquake/disaster drill. 12. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia and those on hospice. On today's visit: Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the caregiver Joel Basiliothe state’s words, verbatim · CDSS document, Jun 19, 2023

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

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegation. LPA met with Joel Basillo and Maryanne Vergara (Caregivers) and explained the reason for the visit. The Administrator Terry McGee showed up shortly after. The investigation consisted of the following: LPA obtained copies of the resident and staff rosters, and interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 - Resident 6 (R1 - R6), and some family members and visitors that visited the facility in September. The investigation revealed the following: regarding the allegation "facility is not following COVID-19 protocols”, it is alleged that the visitor log shows multiple visitor's temperatures were not recorded and missing from the log. (CONTINUED TO LIC 9099C) Unsubstantiated Administrator and staff interviewed denied the allegation and stated that all visitors are Covid-19 screened and their temperature is taken. They provide the temperature to the visitors and ask them to complete the visitor log. Residents interviewed revealed that 3 out of 6 residents were unable to corroborate the allegation. An attempt to interview the other 3 residents was made but was unsuccessful due to either being asleep, refusing to be interviewed or intellectual capabilities. Interviews with the family members revealed that they are Covid-19 screened and their temperature is taken when they come visit. They are asked to complete the visitor log. LPA contacted the visitors that have a missing temperature in the September visitor log and they all confirmed that they were Covid-19 screened and their temperature was taken. However, they forgot to write down their temperature in the visitor log. Facility will ensure from now on that the visitors fully complete the visitors log. In today's visit, the LPA was Covid-19 screened at the entrance and temperature was taken. The staff provided the LPA with the temperature and asked the LPA to complete the visitor log. 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. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Oct 6, 2022 · control 28-AS-20220929161850

Allegation investigated: Staff do not wear masks.

Licensing Program Analysts (LPAs) Christine Wong and Ya Ting Yang conducted a complaint visit to investigate the allegation: Staff do not wear masks. LPA met with staff member Joel Basilio and explained the reason for the visit. A short time later, administrator, Terry McGee arrived. The investigation consisted of the following: LPAs interviewed 6 residents and families, two staff and administrator and reviewed residents' documents/files. The investigation revealed of the following: Allegation "Staff do not wear masks." LPA interviewed 6 residents and five out of six residents denied the allegation and reported the staff always wears mask while they are working. The staff are very causious and follow the Covid 19 protocol. LPA interviewed staff and they reported they both are live in staff. They do wear mask when they serve the residents or provide direct care to the residents such as feeding or showering them. LPAs also observe staff are wearing mask during our complaint investigation. (See LIC 9099C for continuation) Unsubstantiated Based on interviews conducted with residents and staff and LPA's observation, 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. Exit interview conducted. A copy of the report and appeal right was provided to caregiver Joel Basiliothe state’s words, verbatim · CDSS document, Jul 13, 2022 · control 28-AS-20220707163449

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual visit at the facility with focus on the infection control domain. LPA met with caregiver Maryanne Veigara and Joel Basilio explained the reason for the visit. The facility is licensed to serve 6 residents over the age of 60 years old of which 2 ambulatory and 4 non-ambulatory, and a hospice waiver for one resident. There are currently one residents on hospice. Facility cares for dementia residents and has security alarm on each exit doors. There is a swimming pool in the back yard but its gated and locked. LPA and caregiver Joel Basilio conducted a tour of the facility and observed the following: All common areas are clean and in good repair. Kitchen was observed clean, food was reviewed and sufficient for at least 2 days of perishables and 7 days of non-perishables. All residents bedrooms were observed, all bedrooms have sufficient lighting, furniture, and bedding. All three Bathrooms in the facility were observed. The bathroom#1 and #2, the hot water faucet are not working. Water temperature was tested in the three bathrooms and tested between 78.5 and 118.6 degrees F. which is not within the required 105-120 degrees F. LPA reviewed all 6 residents' files and all their emergency contact information are updated. LPA reviewed 3 staff files and LPA was not able to review administrator file including the administrator certificate and health screening form. LPA reviewed all 6 residents medication and all residents medication are updated and accurate. (Please LIC 9099 for continuation) Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, the facility is disinfected every 2 hours, bathrooms have sufficient soap, paper towels, and signs, and PPE supplies are stored for more than 30 days. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations. An exit interview was conducted and a copy of the Facility Evaluation Report and Appeal Rights were provided to Staff #1 (Lead Caregiver).the state’s words, verbatim · CDSS document, Jun 7, 2022

Allegation investigated: Staff are not following Covid-19 protocols.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation to the facility. Upon arrival, LPA met with Joel Basilio (Caregiver) and explained the purpose of the visit. During today's visit, LPA obtained a copy of the staff and resident roster and interviewed Staff #1. Upon entry into the facility, Staff #1 did not provide LPA with a temperature check, did not ask LPA to sign in or wash or sanitize hands. Witness also indicate that during an unannounced visit to the facility on 12/17/21, staff neglected to provide witness with COVID-19 screening and symptoms check. Interview with staff #1 indicate that training was provided to conducted COVID-19 protocols and symptom check but thought that LPA and Witness was exempted from COVID-19 screening. Based on LPA's interview and observations, the investigation revealed 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 and Chapter 8 are being cited on the attached LIC 9099D. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Joel Basilio and a copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Mar 14, 2022 · control 28-AS-20220308123850

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 28, 2022

87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Upon entry into the facility, Staff #1 did not provide LPA with a temperature check, did not ask LPA to sign in or wash or sanitize hands. Witness also indicate that during an unannounced visit to the facility on 12/17/21, staff neglected to provide witness with COVID-19 screening and symptoms check.the state’s words, verbatim · CDSS document, Mar 14, 2022

Plan of correction: Licensee shall provide additional training to all staff regarding COVID-19 protocols and symptom screening to all visitors and provide proof to the department by the POC date. Note: LPA advised all staff present at time of visit to follow COVID-19 protocol.