Sandhill Assisted Living

Type of visit: Office

On 10/4/23 San Bruno Regional Office conducted a non-compliance conference meeting with Licensees, Susan Tilma & Diana Covich. Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, Jackie Jin, and Licensing Program Analyst, Grace Donato. During non-compliance meeting, the following violations were discussed, Reporting Requirements for a change in condition of a resident and elopement, Care of Persons with Dementia for R1 eloping for the second time, not having awake staff, R1 able to leave through perimeter fence unassisted. In addition, during the non-compliance meeting, LPM & LPA delivered an amended deficiencies from a citations on 8/8/2023. During this meeting, it was discussed, Licensee will receive more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providersthe state’s words, verbatim · CDSS document, Oct 4, 2023

Type of visit: Required - 1 Year

On 9/18/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Caregiver Jonathan Mendoza. LPA explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen area & garage. The indoor and outdoor passageways were free of obstruction. At around 11:30 am, the residents were observed to have lunch in dining area.. While touring the facility it was observed that the room temperature was at 71 deg F. Hot water was also tested in the bathrooms and the temperature was 108 deg F. Carbon monoxide monitor are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. All personal belongings of residents are intact. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. Two resident records and two staff records were reviewed. Staff records are complete, with training logs. Facility accepts hospice residents and are in compliance with the required waiver requirements. LPA interviewed two residents and one staff member. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA requested the following documents: Control of Property, Certificate of Liability Insurance, LIC 500. Upon reviewing resident records it was found out that an incident wasn't reported to CCLD. A resident (R1) was sent to ER and no incident report was done or sent to CCLD. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $250 for repeat violation regarding reporting requirements. Please see LIC421FC. This report was reviewed with and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 18, 2023

Type of visit: Case Management - Incident

On 9/1/2023, Licensing Program Analyst (LPS) Grace Donato conducted an unannounced case management visit. LPA met with Caregiver, Jonathan Mendoza. LPA explained the purpose of the visit. LPA received an incident report last 8/29/23 regarding a resident (R1) eloping from the facility. The incident happened on 8/27/23, R1 eloped from the facility around 1am and was returned by Police around 2 am with no injuries. Staff (S1) that currently resides on the facility, but not on shift, did not hear the alarm went off around that time. While LPA was in the facility, R1 was currently having lunch in the dining area. LPA observed that all exit points have a loud alarm when door is opened. Facility also has a main gate which is open the whole day and closed during nighttime. It is unknown which gate R1 used to exit the facility premises. LPA spoke with Licensee, Diana Covich on the phone. There was no reassessment done for R1 after the elopement. Licensee has scheduled a reassessment for the resident.There is no night supervision scheduled in the facility. Based on document review, R1 has wandering behavior. Deficiencies are cited today as the facility did not ensure that residents won’t be able to leave the facility without assistance. Facility also didn’t make sure that R1 had a reassessment after the incident, this is to address any additional care that might be needed. Facility is also being cited for not having night supervision available even when there is a resident who have wandering behavior. Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed and a copy of this report and the Appeal Rights are provided.the state’s words, verbatim · CDSS document, Sep 1, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(5)(A) · Plan of correction due date: Sep 2, 2023

87705 (c)Licensees who accept and retain residents with dementia...(5)Each resident with dementia shall have an annual medical assessment... (A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed... This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above due to R1 not being reassesed after the elopement which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 1, 2023

Plan of correction: Licensee to submit a plan of action and submit the reassessment report (whenever available) to LPA by POC deadline.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(c)(4)(A) · Plan of correction due date: Sep 2, 2023

87705(c) Licensees who accept and retain residents with dementia...(4)There is an adequate number of direct care staff...(A)In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents... This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above due to R1 having wandering behaviors but Licensee did not schedule nigh supervision which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 1, 2023

Plan of correction: Licensee to submit an updated LIC500 which states that there would be a night shift scheduled. Licensee to submit by POC due date.

Type of visit: Case Management - Incident

On 8/8/2023, Licensing Program Analyst (LPS) Grace Donato conducted an unannounced case management visit. LPA met with Licensee, Susan Tilma. LPA explained the pruspose of the visit. LPA received information regarding concerns about male caregiver (S1) “ripping clothes” of a female resident (R1). Another report regarding a resident (R2) eloping on 6/27/23. On the concern about a S1 “ripping clothes” of R1, based on interviews, it cannot be confirmed that said incident happened due to R1 passing. R1 has been on hospice and has dementia. With regards to R2 eloping, no record of the incident was reported to the facility. Based on interviews, Licensee mentioned that they weren't able to report the incident to CCLD. R2 likes walking around the facility. R2 was able to exit on one of the gates. On the day mentioned, R2 was able to go out unsupervised. Based on record reviews, resident has dementia and should not be able to leave the facility without supervision. Deficiencies are cited today as the facility did not ensure the elopement incident was reported on a timely manner to CCLD. Also, the facility staff wasn't able to supervise the R2 while going around the facility leading him to leave unaccompanied/unsupervised. Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed and a copy of this report and the Appeal Rights are provided.the state’s words, verbatim · CDSS document, Aug 8, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(h) · Plan of correction due date: Aug 9, 2023

Amended 87705(h)Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.This requirement was not met as evidenced by: Based on ord reviews and interviews, the licensee did not comply with the section cited above due resident with dementia being able to leave facility unassited which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 8, 2023

Plan of correction: Licensee to submit a plan and in-service training for staff about Dementia plan of operation of the facility. Licensee to submit to LPA by 8/9/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Aug 15, 2023

Amended to Type A 87211(a) Each licensee shall furnish... such reports... including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency...(D)Any incident which threatens the welfare...or unexplained absence of any resident. This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above due incidents not being reported to CCLD which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 8, 2023

Plan of correction: Licensee to submit a plan of action regarding timely submission of incident reports. Licensee to submit to LPA by 8/15/23.

Type of visit: Prelicensing

On 11/16/2022, Licensing Program Analyst (LPA) Murial Han conducted a follow-up pre-licensing inspection from the initial pre-licensing that was done on 10/25/2022. LPA met with lead staff, Averelle Aban and the administrator, Susan Tilma arrived shortly thereafter to complete the inspection. During today's inspection, lead staff provided a tour of the facility and LPA inspected the area of concerns that were identified during the initial inspection. LPA observed the medication, and the chemical/toxins were appropriate stored, locked and inaccessible to residents. The first-aid kit is inspected and complete. The kitchen sink, the bath/shower rooms water temperature were measured at 105.1 to 105.8 degrees Fahrenheit (F). As a result of today's inspection, the area of concerns from the initial inspection have been resolved. Pre-Licensing is now complete. Immediate Licensure is recommended pending final approval from the Central Applications Bureau. Comp III orientation was given to the Administrator, Susan Tilma and Lead Staff, Averelle Aban. This report is reviewed and discussed with the administrator. A copy of the report is provided.the state’s words, verbatim · CDSS document, Nov 16, 2022

Type of visit: Prelicensing

On 10/25/2022, Licensing Program Analyst (LPA), Murial Han met with the Administrator, Susan Tilma and conducted an unannounced Pre-Licensing inspection. LPA observed the indoor and the outdoor passageways are free of obstruction. LPA toured facility and grounds. This is a single level facility. The facility has 6 private resident rooms, 3 staff rooms, 2 resident bathrooms, 1 visitor bathroom and 1 staff bathroom. There is 5 residents during the time of the inspection. LPA observed good lighting and comfortable temperature in the facility. The living room and the dining room is observed to be comfortable, spacious with adequate furniture. LPA observed sufficient hygiene and cleaning supplies. The refrigerator was measured at 35 degrees Fahrenheit (F) and the freezer was measured at 0 degrees F. Dry goods/emergency food supplies are stored in the garage.. LPA observed COVID-19 signs posted by the entrance, within the facility, hand washing instruction signs by the hand washing stations and other postings such as the Licensing Complaint Poster, Resident Rights, etc. Pre-Licensing is incomplete during this inspection due to the following observations: - Medication is stored at a centralized area, however, it was not properly locked - Chemicals, disinfectants, cleaning solutions, etc. are not properly locked - Facility did not have a first aid kit - The facility did not have a thermometer to measure the hot water temperature The administrator acknowledged the above findings and LPA recommended the facility to review the pre-licensing checklist prior to the follow-up inspection. Deficiencies for today's findings will be cited under facility Orchid Villa Residential Home, facility # 410508820. Exit interview conducted with administrator. A copy of this report is provided The administrator acknowledged the above findings and LPA recommended the facility to review the pre-licensing checklist prior to the follow-up inspection. Deficiencies for today's findings will be cited under facility Orchid Villa Residential Home, facility # 410508820. Exit interview conducted with administrator. A copy of this report is provided.the state’s words, verbatim · CDSS document, Oct 25, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(8) · Plan of correction due date: Nov 1, 2022

87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility...8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available.... This requirment is not met as evicenced by: the facility did not have a first aid kit for LPA to inspect during the pre-licensing inpsection which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: The administrator will review this requirement and obtain a complete set of first aid kit for the facility. The administrator will provide in-service to staff on the importance of having a first aid kit in the facility, to ensure it contains the required items and the location of the first aid kit. The administrator will submit proof that the first aid kit is obtained, properly stored and provide a copy of the in-service record to CCL by 11/1/2022.

Type of visit: Prelicensing

On 10/25/2022, Licensing Program Analyst (LPA), Murial Han met with the Administrator, Susan Tilma and conducted an unannounced Pre-Licensing inspection. LPA observed the indoor and the outdoor passageways are free of obstruction. LPA toured facility and grounds. This is a single level facility. The facility has 6 private resident rooms, 3 staff rooms, 2 resident bathrooms, 1 visitor bathroom and 1 staff bathroom. There is 5 residents during the time of the inspection. LPA observed good lighting and comfortable temperature in the facility. The living room and the dining room is observed to be comfortable, spacious with adequate furniture. LPA observed sufficient hygiene and cleaning supplies. The refrigerator was measured at 35 degrees Fahrenheit (F) and the freezer was measured at 0 degrees F. Dry goods/emergency food supplies are stored in the garage.. LPA observed COVID-19 signs posted by the entrance, within the facility, hand washing instruction signs by the hand washing stations and other postings such as the Licensing Complaint Poster, Resident Rights, etc. Pre-Licensing is incomplete during this inspection due to the following observations: - Medication is stored at a centralized area, however, it was not properly locked - Chemicals, disinfectants, cleaning solutions, etc. are not properly locked - Facility did not have a first aid kit - The facility did not have a thermometer to measure the hot water temperature The administrator acknowledged the above findings and LPA recommended the facility to review the pre-licensing checklist prior to the follow-up inspection. Deficiencies for today's findings will be cited under facility Orchid Villa Residential Home, facility # 410508820. Exit interview conducted with administrator. A copy of this report is providedthe state’s words, verbatim · CDSS document, Oct 25, 2022

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 6 Census (if any clients in care): 5 COMP II Participants: Diana Covich, Corporate Board Member Interview Method: Telephone interview On September 29, 2022 at 10:00 AM, Applicant participated in COMP II. Identification of the Applicant was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant confirmed the understanding of the California Code Title 22 Regulations. During COMP II, CAB Analyst confirmed Applicant's nderstanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements/CPMB associations & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Corporate Board Member. Copy of report will be sent via email PDF to Administrator and Corporate Board Member and informed to return signed copy by end of business day today.the state’s words, verbatim · CDSS document, Sep 29, 2022