Rosehaven 1

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety case management visit. LPA was greeted and granted entry into the facility by Caregiver Antonio Gaspi and explained the reason for the visit. During the visit, LPA toured the facility and spoke with residents. LPA observed fans in all resident rooms as well as common areas. LPA spoke with three out of four residents who confirmed the facility was appropriately cooled. Residents verbalized satisfaction with the facility and appeared happy and well taken care of. Facility temperature during today's visit was 73 degrees F. Based on the observations made during today's visit, no deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 28, 2022

Allegation investigated: Staff do not follow physicians orders to transfer resident every 2 hours Staff did not provide resident's authorized representative with a copy of the Admission Agreement within the required time frame Staff are not adequately trained to meet resident needs

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility today to deliver findings on the above allegations. LPA Lyman met with Caregiver Brenda Castillo and discussed the reason for visit. Administrator Jaya Pichika arrived during the visit. During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as admission agreement and staff training. Regarding the allegations that staff do not follow physicians orders to transfer resident every 2 hours, staff did not provide resident's authorized representative with a copy of the Admission Agreement within the required time frame and Staff are not adequately trained to meet resident needs, the investigation revealed the following: Resident 1 (R1) has a physician order dated 07/01/2022 indicating R1 is to be turned every two hours by facility staff. Two out of two staff state the resident is being turned every two hours. However, facility checklist for two hour turns indicate between July 1-12, 2022, it was not documented 24 times that the resident was turned. Additionally, witness indicates resident is not be turned regularly at night. Staff indicate their shift ends at 6 PM but work as needed to CONTINUED ON 9099C DATED 07/29/2022 Substantiated turn resident throughout the night. R1 admitted into the facility on 04/22/2022. Responsible Party states not receiving a copy of the admission agreement and Licensee/ Administrator admits to not providing a copy of the admission agreement. During the investigation, LPA reviewed staff training records. Two out of four facility staff do not have documented required training. Based on observations made and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of .Regulations, (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conductedthe state’s words, verbatim · CDSS document, Jul 29, 2022 · control 22-AS-20220705085643

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 30, 2022

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by: Based on record review, Licensee failed to ensure care and supervision is being provided to R1. R1 has a physician order to turn resident every 2 hours. Facility documentation indicates R1 was not turned 24 times between July 1-12, 2022. This poses an immediate health and safety risk to residents in care. Civil Penalty Assessed.the state’s words, verbatim · CDSS document, Jul 29, 2022

Plan of correction: Licensee to submit a detailed, written plan on ensuring resident is being turned every two hours per physician order and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Jul 30, 2022

The licensee shall provide a copy of the signed and dated current admission agreement.., to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification...This requirement is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure an admission agreement was provided to R1/ Responsible Party. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2022

Plan of correction: Licensee to provide a copy of the signed admission agreement to R1/ Responsible Party and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c) · Plan of correction due date: Aug 12, 2022

Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not being met as evidenced by: Based on record review, Licensee failed to ensure verification of staff training is maintained. Two out of four staff do not have documentation of required training. This poses a potential health and safety risk to residents in are.the state’s words, verbatim · CDSS document, Jul 29, 2022

Plan of correction: Licensee to ensure all staff training is up to date and verification is maintained in staff file. Licensee to forward proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20220705085643. LPA was greeted and granted entry into the facility by Caregiver Brenda Castillo and explained the reason for the visit. Administrator/ Licensee Jay Pichika arrived during the visit. During the course of the complaint visit, LPA met with Staff 1 (S1). S1 indicates working at facility for a week. LPA observed through Guardian and LIS that S1 is not associated to the facility. Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Jul 29, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(c) · Plan of correction due date: Jul 30, 2022

A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: This requirement is not being met as evidenced by: Based on interview and record review, Licensee failed to ensure S1 is associated to the facility. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, Jul 29, 2022

Plan of correction: Licensee to submit LIC 9182 or associate the staff in the Guardian system and forward proof to LPA by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 05/17/2022. LPA was greeted and granted entry into the facility by Caregiver Antonio Gaspi and explained the reason for the visit. Jaya Pichika arrived during the visit. *Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. Licensee cleared noted items. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87506(d) pertaining to Resident Records has been cleared. Resident records are on-site during today's visit. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Care of Persons with Dementia has been cleared. Licensee secured noted items. Licensee has complied with the terms of the POC. Licensee has been advised to maintain all items in compliance with Title 22 regulations. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 12, 2022

Type of visit: Office

Licensing Program Manager (LPM) Alisa Ortiz, and Licensing Program Analyst (LPA) Kimberly Lyman, conducted an informal office meeting via teams application with Licensee Jaya Pichika to discuss general compliance concerns at the facility. The following items were discussed during the meeting: Staffing levels and schedule. Physical plant issues. Lack of communication between licensee and the department. Non-compliance with citations. Licensee agrees as follows: Licensee to communicate with the department on all issues or concerns regarding facility operations. Licensee agrees to contact department for clarification and not make assumptions. Licensee to forward a copy of the LIC 500 to LPA by 06/23/2022. Facility will maintain compliance of Title 22 at all times and failure to maintain compliance may result in the department taking further action. During the visit, Licensee was offered technical support services with the department to assist with compliance. Licensee declines the technical support and states she has made the corrections and is confident there will be no issues moving forward. Exit interview conducted and a copy of this report will be emailed to Licensee for signature due to the visit being virtual.the state’s words, verbatim · CDSS document, Jun 16, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Jericho De Castro and explained the reason for the visit. LPA spoke with Administrator Pichika via FaceTime. At 10:40 AM, LPA toured the facility with Caregiver DeCastro. Facility has four residents in care during today's visit with one on hospice care. LPA observed residents relaxing in their rooms or in common areas. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. At 10:45 AM, LPA observed the attic door is in need of repair. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as required department postings. At 10:47 AM, LPA observed unsecured Ajax in the master suite restroom cupboard as well as cupboards missing cupboard pulls on cabinet. At 10:52 AM, LPA observed unsecured Windex in the common restroom. LPA toured the kitchen and observed ample food supply as well as emergency food and water in the garage. At 10:56 AM, LPA observed broken cabinet doors in the kitchen as well as unsecured sharps in an unlocked cupboard (photos). Facility has completed the mitigation plan and the plan has been approved. LPA observed the first aid kit contained all required items and medications are stored secured in a locked cabinet. LPA toured the outside grounds and observed the outside visitation area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA unable to review resident files as files are not on-site at the facility. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, May 17, 2022

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 03/21/2022. LPA was greeted and granted entry into the facility by Caregiver Red Santos and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. Licensee cleared noted items. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87468.2(a)(2) pertaining to Personal Rights has been cleared. Licensee removed camera in living room. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87405(a) pertaining to Administrator Qualifications has NOT been cleared. Licensee did not provide proof of correction. Licensee has NOT complied with the terms of the POC. CIVIL PENALTY ISSUED. *Deficiency cited under Title 22 Regulation 87468.2(a)(1) pertaining to Personal Rights has NOT been cleared. Licensee did not provide proof of correction. Licensee has NOT complied with the terms of the POC. CIVIL PENALTY ISSUED. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 5, 2022

Allegation investigated: Administrator did not provide residents with privacy. Administrator not demonstrating good character required of the position. Administrator did not treat resident with dignity. Facility is in disrepair. Facility has pests.

Licensing Program Analysts (LPAs) Kimberly Lyman and Edward Tapia made an unannounced visit to the facility today to deliver findings. LPAs met with Caregiver Amparo Mancillas and discussed the reason for visit. Administrator Jaya Pichika arrived during the visit. During the course of the investigation, LPA toured the facility and interviewed staff and witnesses. Regarding the allegations that Administrator did not provide residents with privacy, Administrator not demonstrating good character required of the position, Administrator did not treat resident with dignity, facility is in disrepair and facility has pests, the investigation revealed the following: On October 19, 2021, Resident 1 (R1) was actively passing. Family members were present at the time. Three out of four witnesses interviewed state hearing a verbal altercation between Administrator and R1's family member in R1's room with family member requesting the administrator to leave the room. Witnesses state the altercation was heated and occurred while the resident was passing. Witnesses indicate Administrator is very vocal in disagreements with staff in front of families and residents. Administrator admits a video camera was put CONTINUED ON LIC 9099C DATED 03/21/2022. Substantiated up in the living room without consent from responsible parties but states it was removed after reviewing licensing regulations. Witnesses confirm the video camera was in the living room. During tour of the facility, LPA observed items in disrepair in the facility including broken cupboards, an entrance ramp in disrepair, broken furniture on the patio, and kitchen cupboard missing molding. During the course of the investigation, LPA observed that Administrator has not had a current administrator certificate since 09/30/2019. LPA observed cockroaches in the kitchen cupboards and resident room. Based on observations made and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of .Regulations, (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. Citation previously issued on 11/02/2021 for the allegation of facility in disrepair Citation issued previously on 11/23/2021 facility has pests. Citation previously issued on 11/02/2021 for lack of current administrator certificate. Exit interview conducted and a copy of the report provided as well as appeal rights..the state’s words, verbatim · CDSS document, Mar 21, 2022 · control 22-AS-20211025141423

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Mar 28, 2022

In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents.. shall have all of the following personal rights: To have a reasonable level of personal privacy in accommodations... and meetings of resident and family groups. This req not being met.. Based on interviews conducted, Licensee failed to ensure a reasonable level of privacy was provided to residents. Administrator admits to putting a video camera up in the living room without any consent from residents or responsible parties. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2022

Plan of correction: Licensee removed the camera prior to complaint investigation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d) · Plan of correction due date: Apr 4, 2022

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not being met as evidenced by: Based on observation and interviews conducted, Licensee did not have qualifications for operation of facility. Administrator does not have a current certificate and allowed personal rights violations, pests in the facility, and facility to be in disrepair. This poses a potential health, safety, or personal rights violation.the state’s words, verbatim · CDSS document, Mar 21, 2022

Plan of correction: Licensee to provide a written statement of understanding administrator qualifications and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Mar 22, 2022

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure resident is accorded dignity. During R1's passing, Licensee was involved in a verbal altercation with R1's family member while family member was asking for privacy. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2022

Plan of correction: Licensee to submit a written, detailed plan on how to handle family discussions privately and with dignity and forward proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kimberly Lyman and Edward Tapia conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20211025141423. LPAs were greeted and granted entry into the facility by Caregiver Amparo Mancillas and explained the reason for the visit. Administrator/ Licensee Jay Pichika arrived during the visit. During the course of the complaint visit, LPAs observed the following: There are various discarded items such as bed frame, mattress, pulley, broken drawers and AC unit in driveway area. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Mar 21, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 4, 2022

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 being met as evidenced by: Based on observation, Licensee failed to ensure facility is clean, safe, and sanitary. LPAs observed discarded items in the front of the driveway. This poses a potential health and safety risk to residents in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Mar 21, 2022

Plan of correction: Licensee to remove discarded items in front of driveway and forward proof to LPA by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 11/02/2021. LPA was greeted and granted entry into the facility by Caregiver Dominga Santillian and explained the reason for the visit. Administrator Jaya Pichika arrived during the visit. *Deficiency cited under Title 22 Regulation 87211(a)(1)(A) pertaining to Reporting Requirements has been cleared. Administrator provided requested death report. Licensee has complied with the terms of the POC. *Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. LPA observed Licensee has repaired/ replaced noted items. Licensee has complied with the terms of the POC. Advisory note issued on 11/02/2021 advised the following: Facility does not have the "Let Us No" poster in the facility at correct size. Please post in regulation size, 20" X 26" Facility has not posted the poster in regulation size. During the tour of the facility, LPA observed live and dead cockroaches in the kitchen and in resident room. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Nov 23, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(c)(2)(A) · Plan of correction due date: Dec 7, 2021

Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents...Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) ... The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. This req is not being met as evidenced by: Based on observation, Licensee failed to ensure the "Let Us No" poster is posted in the entrance of the facility in regulation size, 20" X 26." This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 23, 2021

Plan of correction: Licensee to post the poster in regulation size and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(d)(2) · Plan of correction due date: Nov 30, 2021

The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not being met as evidenced by: Based on observation, LPA observed live and dead cockroaches in the kitchen and resident bedroom. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 23, 2021

Plan of correction: Licensee to repaire broken cupboards and exterminate cockroaches. Licensee to forward proof to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident report submitted to Community Care Licensing on 11/17/2021. LPA was greeted and granted entry into the facility by Caregiver Dominga Santillian and explained the reason for the visit. Administrator/ Licensee Jay Pichika arrived during the visit. Incident report dated 11/17/2021 indicated Resident 1 (R1) was taken to the urgent care due to possible UTI and Depakote overdose. Administrator stepped out of urgent care for a zoom meeting. Urgent care determined R1 needed to be seen at the emergency room and was unsuccessful in reaching the administrator. Per witnesses, urgent care reached out to facility staff as well as responsible party to advise of the situation. Administrator states being unable to answer phone due to the administrator's zoom call. Administrator made contact after the zoom call and R1 was sent to the emergency room. R1 was diagnosed with a urinary tract infection. R1's levels of Depakote were deemed to be acceptable and facility continues to follow the medication orders on file as responsible party is in contact with physician to change the order to a lower dose. Witnesses interviewed indicate R1 is currently incontinent and incontinence care is not being provided at night. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Nov 23, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 24, 2021

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure R1 was provided care and supervision. Licensee was unable to receive urgent care's calls due to an appointment Administrator was on. R1 was being transferred to the emergency room. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 23, 2021

Plan of correction: Licensee to submit a statement indicating understanding of care and supervision and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(1) · Plan of correction due date: Dec 7, 2021

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure incontinence care is being provided as needed. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 23, 2021

Plan of correction: Licensee to submit a written plan indicating how incontinence care will be provided and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Dominga Santillian and explained the reason for the visit. Administrator/ Licensee Jay Pichika arrived during the visit. At 10:00 AM, LPA toured the facility with Caregiver Santillian. Administrator Pichika joined the tour in progress. Facility has three residents in care during today's visit. LPA observed residents relaxing in their rooms or in common areas. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. At 10:10 AM, LPA observed a floor tile coming up in the master suite. Hand washing signs are posted throughout the restrooms. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as most required department postings. Administrator Pichika has an administrator certificate that expired on 09/13/2019. LPA observed a bed and discarded items sitting on the driveway as well as an ramp needing repair (photos). LPA toured the kitchen and observed ample food supply as well as emergency food and water. At 10:20 AM, LPA observed a broken cabinet door in the kitchen as well as missing molding on the top of kitchen cupboards. Facility has completed the mitigation plan and the plan has been approved. LPA observed the first aid kit contained all required items and medications are stored secured in a locked cabinet. LPA toured the outside grounds and observed the outside visitation area. LPA observed a patio set with broken cushions and table decorations are peeling off the table. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all files which contained required documentation including emergency information and updated physician reports. LPA consulted with Administrator regarding the importance of maintaining an ample supply of N95 masks on-site at all times. Based on the observations made during today's visit, CONTINUED ON LIC 809C DATED 11/02/2021 the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Nov 2, 2021

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20211025141423. LPA was greeted and granted entry into the facility by Caregiver Dominga Santillian and explained the reason for the visit. Administrator/ Licensee Jay Pichika arrived during the visit. During the course of the complaint investigation, LPA requested the file and death report for Resident 1 (R1). Facility does not have the file for resident nor had submitted the death report. LPA consulted with Administrator regarding the importance of reporting incidents and death reports timely. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Nov 2, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b) · Plan of correction due date: Nov 2, 2021

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 being met as evidenced by: Based on observation and record review, Licensee failed to ensure R1's file is maintained at the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2021

Plan of correction: Licensee to provide proof of R1's file to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(A) · Plan of correction due date: Nov 9, 2021

Each licensee shall furnish to the licensing agency such reports as.., including.., the following: Death of any resident from any cause regardless of where the death occurred... This requirement is not being met as evidenced by: Based on interview conducted, Licensee failed to ensure a death report for R1 was submitted to Licensing. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2021

Plan of correction: Licensee to forward death report to LPA by POC due date.