Rose Waters Home

Type of visit: Required - 1 Year

On 07/20/2023 at 12:25 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Rose Kamau and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory. LPA toured facility with Rose including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. LPA observed a locked gate surrounding the pool. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms was measured at 110.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last purchased on 02/14/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 05/16/2023. Report continues on 809 C. At 1:10 PM, LPA reviewed 6 of 6 residents records. At 1:50PM, LPA reviewed 5 of 7 staff records and 5 of 5 have current first aid training and associated to the facility. At 12:55 PM, LPA reviewed a sample of 6 of 6 resident’s medications. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/10/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 20, 2023

Type of visit: Required - 1 Year

On 09/01/2022 at 3:00 pm, Licensing Program Analysts (LPAs) C. Fowler and P. Watson arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Rose Kamau and explained the purpose of the visit. Approximately 4:15 pm, Administrator Chaba Bender arrived. Upon entry, LPAs observed screening station that contained hand sanitizer, masks and COVID signage. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPAs observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters. During record review, LPA observed visitors log and temperature logs for residents or staff. LPAs observed facility has a copy of Mitigation. The following deficiencies were observed during the visit: -At 3:05 pm , LPAs observed volunteers not associated to facility. -At 3:11 pm, LPAs observed ant/roach/spider spray The 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. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 1, 2022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility did not issue a proper refund.

On 7/1/2022 at 10:45 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct complaint investigation for the above allegation. Upon arrival, LPAs were greeted by Care Staff Samantha Bender. Administrator, Rose Kamau later arrived at 10:57 AM. During the complaint investigation, LPAs obtained information, interviewed S1, reviewed records and collected documents. Based on information obtained, it was alleged facility did not issue a proper refund. Record review of Admission Agreement indicates R1 moved into the facility on 3/17/2022 and passed away on 4/9/2022. It was noted that R1's belongings were removed from facility on 4/15/2022. REPORT CONTINUES ON 9099C Substantiated It was alleged facility did not provide resident a copy of Admission Agreement. However, based on the signed admission agreement, it was indicated a copy was given to the resident or resident's responsible party. S1 stated responsible party was provided another copy of Admission Agreement on 5/4/2022, LPAs were unable to determine if resident was provided a copy upon admission. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. An email communication between facility and resident's responsible party indicates a total of $4,862 is owed to R1. However, R1's husband (R2)'s balance of $2,126 and a $500 property damage were deducted from the total amount. Facility was not aware that the funds should not have been commingled, therefore a refund of $2,236 was issued to R1. Based on LPAs record review and interview, the preponderance of evidence standard has been met, therefore the above allegation found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 1, 2022 · control 15-AS-20220621125232

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jul 6, 2022

ADMISSION AGREEMENTS (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. LPAs observed a total $2626 for R2's fees and property damage were deducted from R1's refund which poses a potential personal rights to persons in care.the state’s words, verbatim · CDSS document, Jul 1, 2022

Plan of correction: Administrator will issue a refund to resident and submit a copy of payment to CCL by POC date.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 12/22/2021 at 8:55 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Administrator Chaba Bender and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 22, 2021