Regal Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. Upon arrival, the LPA was greeted by staff. The Administrator, Donald Brodt arrived shortly after and the reason for the visit was explained. Entrance interview conducted. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA began the inspection in the kitchen/food service area at 10:00 a.m. Knives are stored in a drawer next to the oven inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Water temperature was measured in the kitchen sink at it measured at 112.1 degrees Fahrenheit at 10:03 a.m. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature of 75 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and purchased on 07/10/2023. The LPA observed required postings throughout the common space. The last earthquake drill took place on 07/07/2023. Activities were observed in the common areas. Fireplace was observed adequately screened. The LPA observed an adequate supply of emergency food and water. The laundry room is locked and inaccessible. Cleaning supplies and toxins were observed in the laundry room locked and inaccessible. Report Continued on LIC 809C... Report Continued from LIC 809C... RESTROOMS: The resident restroom appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured at110.6 degrees Fahrenheit at 10:19 a.m. At 10:16 a.m., the LPA observed several items in the shower. Items observed unlocked and accessible to resident included: shampoo, conditioner, and body wash. Upon review of R1’s Physician’s Report (LIC 602A) dated 02/23/2023, R1 is at risk if allowed direct access to personal grooming and hygiene items. These items were locked away inaccessible to residents at the time of visit. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. At 10:20 a.m., LPA observed medications and body cleansers in Room #5 accessible to residents in care. Items were immediately locked in the medication’s cabinet. RECORDS: LPA reviewed Resident Records at 10:34 a.m. and Personnel Records at 11:16 a.m. Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Two (2) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. MEDICATIONS: Medications review began at 1:55 p.m. The medications are locked in a cabinet inside the office. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Report Continued on LIC 809C... Report Continued from LIC 809C... INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promote good hand hygiene. The facility has an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jul 21, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Zabel Chochian conducted an unannounced Required Annual inspection. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff and reason for visit was explained. Staff contacted Administrator and reason for visit was explained. Administrator stated that his designated staff will assist LPA with today's visit. Staff and LPA toured the physical plant areas to ensure the facility is in compliance with the Infection control requirements. INFECTION CONTROL: During today’s visit, LPA spoke with the Administrator and staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control appeared to be in compliance during todays visit. Following Technical Advisory note issued: Licensee/Administrator was informed that the following signs should be posted: 1) Updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic, in accordance with personal rights requirements. 2)Signs are posted throughout facility to promote hand washing, cough/sneeze etiquette, and physical distancing. 3) Signs are posted throughout facility to encourage residents to report acute respiratory illness to staff. Facility observed in substantial compliance with infection control practices during today's visit. Exit interview conducted with staff. Copy of report email to Licensee/Administrator.the state’s words, verbatim · CDSS document, Jul 7, 2022

The state marks this report as 4 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility exceeded capacity Facility staff violated residents personal rights

Licensing Program Analyst (LPA) Angel Ascencio conducted an initial 10-day visit to the above facility. LPA met with Administrator Donald Brodt at 11:02 AM and explained the reason for visit. Entrance interview conducted. LPA along with Donald tour the facility inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 regulations. It was alledged that facility exceeded capacity. Starting at 11:30 a.m., LPA interviewed Administrator Donald regarding facility census. Admin stated that they currently have six (6) resident but they have an additional resident #7 (R7) that has been staying at the facility for two (2) months. Donald added that R7 broke their hip about 4 months ago and R7's family had asked Donald if R7 can stay at the facility for 2 weeks until R7 recovers. Continued on LIC 90990-C Substantiated Donald continued, those 2 weeks turned into 2 months that R7 has been living here. R7 is independent but we do help with providing self administration of medication and stand by assist in the showers. R7 sleeps in a recliner in another resident room. Interview with R7 starting at 12:00 PM, revealed that R7 has been at the facility for a few months. R7 confirmed that the facility is proving stand-by assist in the showers and are helping with self administration of medications on a daily basis. At 12:10 p.m., LPA received a copy of R7's Medication Administration Record (MAR) for the month of November 2021 and Physician's Report. Interview with staff #1 (S1) at 12:17 p.m. revealed that the staff are helping R7 with medication and stand-by assist in the showers. At 12:55 p.m. LPA received a copy of R7's August 2021, September 2021 and October 2021 checks for rent payment. Based on interviews and evidence gathered throughout the investigation, the allegation facility exceeded capacity is substantiated at this time. It was also alleged that the facility staff violated residents personal rights. Interview with Donald at 11:30 a.m. revealed that R7 has been staying at the facility for 2 months and is incorporated in all the activities, meals and care on a daily basis. Interview with R7 at 12:00 p.m. revealed that they eat, do activities and help out other resident in need by calling out the staff. R7 also added that they have the freedom to come and go throughout the facility and have access to other part of the house besides other resident bedrooms. Based on interviews and evidence gathered throughout the investigation, the allegation Facility staff violated residents personal rights is substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email to the admin.the state’s words, verbatim · CDSS document, Nov 5, 2021 · control 29-AS-20211029151249

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87158(a) · Plan of correction due date: Nov 6, 2021

87158 Capacity (a) A license shall be issued for a specific capacity which shall be the maximum number of residents which can be provided care at any given time. The capacity shall be exclusive of any members of the licensee's own family who reside at the facility... ensure the provision of adequate care and supervision for the residents. Based on documents gathered, interviews and observations the licensee did not comly with the section cited above as the facility exceeded capacity limits of 7 out 6 residents which poses an immiedate health, safety and personal right violation to persons in care.the state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: Admin will assist in relocation of R7 with in 24 hours. Admin will provide a photograph or statement of proof of R7's relocation to LPA via email @ angel.ascencio@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Nov 19, 2021

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. Based on documents, interviews and observations the licensee did not comly with the section cited above as the licensee accepted and provided care and supevision to a 7th resident thus taking away care needs of those who have a rental agreement and care plans which poses a potential health, safety and personal right violation to persons in care.the state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: Admin will provide training to all staff via outside agency regarding personal rights and will submit proof of training material and attendees to LPA via email at: angel.ascencio@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management visit to the above facility. LPA met with Administrator Donald Brodt at 11:02 AM. Entrance interview conducted. LPA along with Donald tour the facility inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 regulations. Upon tour at 11:15 a.m., LPA counted seven (7) resident in the facility, five (5) where in the dining room, one (1) was in the living room watching television, 1 was in their room. LPA questioned Donald regarding extra resident. Donald stated that resident is staying in Bedroom #2 with another resident. LPA observed the facility sketch and fire clearance and noticed Bedroom #2 is cleared to have only 1 occupancy. Interview with resident #7 (R7) 12:00 p.m. revealed that they are staying with another resident in bedroom number #2. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Civil penalties will be assessed against any facility that fails to take corrective action within described time periods. The facility is hereby notified that a civil penalty will be assessed beginning on 11/5/2021. An Immediate Civil Penalty Assessment of $500.00 has been issued today 11/5/2021 for Fire Clearance. Exit interview conducted. A copy of the report and appeal rights were provided via email to admin.the state’s words, verbatim · CDSS document, Nov 5, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202 · Plan of correction due date: Nov 6, 2021

87202 Fire Clearance All facilities shall maintain a fire clearance approved by the city,county,or city and county fire department, or district providing fire protection services, or the State Fire Marshal...appropriate fire clearance approved by the city,county or city and county fire department, or district providing fire protection services,or the State Fire Marshal. Based on documents gathered, interviews and observations the licensee did not comly with the section cited above as the facility exceeded fire clearance limitations which poses an immiedate health, safety and personal right violation to persons in care.the state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: Licensee will remove resident from room and will find appropriate housing for resident. Licensee will provide photographic or statement proof of resident not resident in Bedroom #2.