Sabile House of Care

Allegation investigated: Facility is not meeting resident's care needs

On 8/3/2023, Licensing Program Analyst (LPA), Tobola arrived unannounced for the purpose of delivering complaint findings and was greeted by Lead Caregiver Staff, Consolacion Espra. Licensee, Rosauro Sabile was contacted but unable to attend visit. LPA Tobola toured the facility, interviewed staff, residents and outside parties, reviewed resident records and made observations during the course of the investigation. Complaint alleges the facility is not meeting resident’s care needs for resident R1. Based on a review of resident’s (R1) physician’s report and care plan, it is not indicated that R1 requires the use of continence care items and also states that R1 can manage their own toileting needs. Upon observation and interviews with residents, staff and outside parties, LPA found that the facility utilizes continence care items for R1, including adult diapers and bed pads. In addition, LPA conducted interviews with multiple outside parties who indicated that they observed resident R1 left in soiled disposable briefs, padding and bedding on multiple occasions. Continued onto LIC9099-C Substantiated Allegation, facility is not meeting resident’s care needs, is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Aug 3, 2023 · control 21-AS-20230512110034

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f) · Plan of correction due date: Aug 10, 2023

87464(f) - Basic services shall at a minimum include care and supervision as described in Health and Safety Code section 1569.2(c). These requirements were not met as evidenced by: Based on a review of records, it is not indicated that R1 requires the use of continence care items. Based on observations, interviews with residents, staff and outside parties, it was found that the facility uses disposable briefs and pads for R1 without documentation of needed use or care plan. In addition, outside parties had observed R1 left in soiled disposable briefs, pads and bedding on multiple occasions. This serves as an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 3, 2023

Plan of correction: Licensee agrees to conduct in-service training for all staff to follow facility care protocols to meet the residents care needs and supervision to change linens and continence care products. In addition, Licensee agrees to update resident R1's Physician's Report and Needs & Service Plan to clearly indicate the use of continence care products for R1. Signed training and updated Physician's Report and Needs & Service Plan are to be submitted to CCLD by POC date 8/10/2023. Completed training signed by staff to be sumbitted by POC date 8/4/2023.

Allegation investigated: Neglect/Lack of Care and Supervision resulted in resident sustaining severe injuries

On 7/28/2023, Licensing Program Analyst (LPA), Tobola arrived unannounced for the purpose of delivering complaint findings and was greeted by Lead Caregiver Staff, Consolacion Espra. Licensee, Sabile Rosauro was contacted but unable to attend visit. This department has investigated the allegations by taking tours of the facility, conducting interviews of staff, residents, and outside parties, reviewing resident records during the course of the investigation. Complaint alleges Neglect/Lack of Care and Supervision resulted in resident sustaining severe injuries. Based on a review of incident reports and medical records it was found that resident (R1) had been sent to Sutter Solano for medical attention on 3/10/2023. Medical records indicate that R1 had been admitted to the Sutter Solano Medical Center on 3/10/2023 after facility observed R1 to be bedbound for two days (3/8/2023-3/9/2023) without energy. Upon admission to the medical center, R1 was assessed and observed to have a total of 17 wounds, including multiple pressure ulcers, a stage one pressure injury to R1's right hip and an unstageable severe traumatic injury to R1's right wrist/hand resulting in amputation of R1's right hand. Continued onto LIC9099-C Substantiated Interviews with facility Licensee and caregiver staff (S1 & S2) state that these individuals did not observe or were aware of any bruises, sores or injuries on R1's body. Although R1 does not require bed reposition based on R1's physician's report, staff were aware of R1's behavior of sitting on their hands and R1's right had appeared red on 3/9/2023. This resulted in severe ischemia potentially due to R1 not being monitored and R1's hands not moved or off-loaded until the following morning on 3/10/2023. Staff did not provide proper assessments and supervision regarding R1's multiple pressure wounds that were observed by emergency ambulance staff and medical center staff upon R1's admission to Sutter Solano Medical Center. Interviews with Sutter Solano Medical physician and registered nurse staff (I1 & I2) indicated that R1's wounds to the right hip and wrist/hand was potentially caused from cut blood flow circulation for a "prolonged time" and "at least several hours" without staff providing proper supervision, assessments and observation of R1's wounds and overall health condition while in the facility. Today, 7/28/2023 the Department An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).the state’s words, verbatim · CDSS document, Jul 28, 2023 · control 21-AS-20230313123922

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jul 29, 2023

87466: Observation of the Resident. Licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning & appropriate assistance is provided when such observation reveals unmet needs. When changes such as...deterioration of mental ability or a physical health condition are observed, Licensee shall ensure that such changes are documented & brought to the attention of the resident's physician & the resident's responsible person, if any. Requirement is not met as evidenced by: Based on Department investigation, resident (R1) sustained mulitple pressure injuries and severe injury resulting in amputation which poses an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Jul 28, 2023

Plan of correction: Administrator agrees to schedule training with an approved outside vendor for all care staff with for all staff regarding observation of a residents. Plan for training to be submitted to CCL by POC due date. Proof of training including trainer, topics covered, date and time spent and attendees to be submitted by 8/11/ 2023. Additionally, Administrator will provide company protocol outlining how residents are observed for changes and how those changes are reported to management. Writtten plan to be submitted by POC date 7/29/2023. “An immediate civil penalty in the amount of $500.00 is issued today for the violation of a regulation resulting in bodily injury or illness of a person in care. As a result of client’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49(f). At this time, the civil penalty assessment is under review.”

Allegation investigated: Resident is inappropriately restrained

On 3/14/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings. LPA toured the facility, interviewed staff, residents, reviewed resident records and made observations. Complaint alleges that resident is inappropriately restrained. Based on interview, Licensee stated that resident (R1) uses a lap belt harness within their wheelchair to prevent resident from falling. Based on a review of R1's medical records LPA found that R1 does not have a documented physician orders on file allowing the use of the lap belt. Allegation, resident is inappropriately restrained is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given Substantiated In addition, LPA observed residents listening to music or news with additional puzzles and word problem books available. In addition, residents R2 and R3 both stated that they prefer activities like radio, television, exercise and stretching with no complaints. Based on interviews, R1 stated that they "do not know" what activities they participate in. Licensee stated that residents previously attended day programs but have since closed. Licensee stated that they are working on integrating additional activities. Complaint alleges that facility failed to meet resident care needs. Based on observation LPA found staff to be attentive and interactive with residents, providing continence care and general cleaning of resident bedrooms. Residents were observed to be communicative, comfortable and in positive demeanor. LPA observed breakfast and lunch served at the facility with generous portions and healthy items. LPA interviewed residents (R1, R2 & R3 all of which stated that the amount of food served is generous. R2 and R3 claimed that the food is served 3 times daily and enjoyable with snacks offered throughout the day. R3 stated that they do not know if they received snacks. Based on interviews with staff and residents, LPA found that residents primarily receive sponge baths as opposed to showers. Licensee stated that the residents are offered regular baths but prefer sponge baths as residents often refuse bathing. LPA interviewed R2 who stated that residents are encouraged but does not like to take regular baths because of the work it takes for R2. R2 also stated that they prefer receiving sponge baths and have no complaints of staff neglecting continence care. LPA did not observe any foul smells or lack of continence care during inspections. Allegations, facility does not provide appropriate activities for residents and facility failed to meet resident care needs are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Appeal Rights given.the state’s words, verbatim · CDSS document, Mar 14, 2023 · control 21-AS-20221116095116

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(1) · Plan of correction due date: Mar 15, 2023

87608(a)(1) Postural Supports. Postural supports may be used to achieve proper body position and balance, improve mobility and independent functioning or to position rather than restrict movement. This requirement is not met as evidenced by** Based on interviews with Licensee and observations; LPA found that facility utilizes waist strap/harness for resident (R1) without physician's orders. This poses an immediate Health, Safety or Personal Rights risk to Clients in care.the state’s words, verbatim · CDSS document, Mar 14, 2023

Plan of correction: Licensee agrees to contact R1's physician and obtain orders for use of waist strap/belt. Once received, Licensee to submit exception request to CCLD. LIC9098 form is to be submitted to CCLD by 3/15/2023 confirming contact with physician. Lastly, Licensee is to conduct a review of all residents' care needs and update Needs & Service Plans. Updated plans to be submitted to CCLD by POC date 3/24/2023.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by staff, Rodger Banzon. Administrator, Rosauro Sabile arrived later during the visit. The facility currently provides care for 5 residents some of which with a of diagnosis of dementia and none of which receiving hospice services. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Staff and Administrator. Facility was at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 2/7/2022 at the time of the visit. Smoke and carbon monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. Residents were observed to be engaged with staff in the living room area participating in television and conversation with one another. Along with residents receiving physical therapy services, facility staff have an exercise period for residents with several equipment items offered daily during afternoons. Toxins are stored in a locked cabinet in the facility garage and under kitchen sinks. During in the tour LPA observed two bottles of bleach located in separate restroom cabinets to be accessible to residents (photos taken). Items were immediately secured. There was a supply of hygiene products and paper products available for resident use. All residents bedrooms have lighting & appropriate furnishings. LPA conducted a sample review of staff training and found that all staff have current CPR and 1st Aid training on file. Continued onto LIC809-C Upon observation of resident exit doors, LPA found that one auditory alarm in resident bedroom to be inoperable. In addition, LPA found a damaged door handle lock leading resident bedroom into the garage containing cleaning supplies and other items that could pose danger if accessible. Infection Control Facility has submitted an Infection Control Plan for review. Posters are located at the facility entrance, common areas and restrooms indicating COVID protocols and mitigation. Facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors, clients and staff. Staff and clients are also screened on a daily basis for temperatures and symptoms. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. LPA requested the following documents be sent to CCL by COB 11/30/2022: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate(s) Copy of Certificate of Liability InsuranceIthe state’s words, verbatim · CDSS document, Nov 23, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Sabile House of Care for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Care Giver, Rogelio Banzon, and granted access into the facility. Administrator, Rosauro Sabile arrived 1 hour later. LPA toured the facility and found the facility is clean, in good repair and at a comfortable temperature with all exits free from obstruction. Exits doors are equipped with working auditory devices. Fire Extinguisher located in the kitchen was found to be charged and serviced on 02/2021. Smoke detectors and carbon monoxide detectors were found to be all operational during the visit. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees F . There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods and the refrigerator was clean. Toxins are stored in key locked cabinets under the kitchen and bathroom sinks. There was an ample supply of hygiene products, linens and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. Resident's medication centrally stored and locked. First Aid kit was inspected and found to be appropriate. All bedrooms have lighting & appropriate furnishings. Required postings viewable in public areas. LPA requested Facility to update the Emergency Disaster Plan. LPA also requested the following documents to be sent to the Regional Office, LIC 309, LIC 400, LIC 308, updated facility sketch, LIC 500 and updated liability insurance. LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has not been N95 Fit tested. PPE is sufficient in the facility. Staff has not had any training in PPE. No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the Facility Administrator.the state’s words, verbatim · CDSS document, Dec 23, 2021

The state marks this report as 10 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.