Southland Home

Type of visit: Required - 1 Year

Licensing Program Analyst’s (LPA’s) De Leon and Jeffries arrived at 9:00 am and made an unannounced 1-year required annual visit to the facility above. LPA’s meet with Nerieda Leal and Ricardo Navarro, Back up's to Administrator and explained the purpose of the visit. LPA’s requested a staff roster, a resident roster, emergency and disaster plan, documentation of quarterly emergency drills. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, covid signs, complaint poster, personal rights, LTCO poster, Bill of Rights and Right to Residential Council. The facility has 4 bedrooms, 3 bathrooms, kitchen, dining room, living room, activity room, laundry room, medication room, back yard enclosed with table, chairs and shade for resident use. Facility currently occupying 4 Residents and 9 staff. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides working telephones and on-line access for resident use. The dual smoke detectors and carbon monoxide detectors are hard wired and in bedrooms and common area. Fire extinguishers were last inspected 05/18/2022 and all show charged in the green. There are no issues with Fire Clearance. Living and dining rooms furniture were also checked for functionality and condition. The living rooms are clean, safe and sanitary along with the dining rooms. The side gates are no longer self-closing or self-latching. There are no bodies of water on the premises. There is plenty of outdoor lighting available for the safety of the residents. Continued on 809C. The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. The sample menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. The Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, night stand and enough lighting for each resident. Residents arranged the rooms the way they want them. There is enough linen available to change weekly or more if need. The Laundry room is kept locked and all detergents and supplies are locked. Towels and washcloths are not shared. Residents have a sufficient amount of supplies for personal hygiene. Soap, toilet paper and paper towels are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms. Resident records were reviewed for requirements and legibility: LPA reviewed 4 resident’s files for current Medical Assessments with TB, Current Appraisal Needs and Service plans (TCRC IPP) , and signed Admission Agreements. Planned activities are offered to residents in care. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 4 staff for criminal record clearances/associations, Health screening were not present in 2 of 4 files reviewed, TB results for all 4, current First Aid/CPR, caregivers/Med-tech annual training and Administrator Certificate expires 08/22/2024. Medications are in a centrally stored and locked medication room, including over-the-counter medicines; Medications are properly labeled. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instruction are followed. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Mar 13, 2023

The state marks this report as 10 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility is misusing resident's funds.

Licensing Program Analyst De Leon conducted a subsequent Complaint visit to deliver final findings to the facility above. LPA arrived at 1:15 PM to the facility. LPA met with Nereida Leal, Staff back up to Administrator at 2:10 pm and explained the purpose of the visit. LPA De Leon conducted the initial complaint visit on 02/01/2023 at 10:00 am, conducted interview at 10:15 am and requested records for Resident 1 and reviewed some of R1’s records. LPA interviewed Witnesses on 01/25/2023, on 01/31/2023 at 11:33 am, on 02/06/2023, on 02/13/2023. LPA De Leon reviewed R1’s additional records on 02/24/2023 and 02/25/2023. Continued 9099-C Unsubstantiated On the allegation: Facility is misusing resident's funds. LPA conducted interviews with staff and witnesses that revealed the debit transactions and reimbursements for the transactions listed in this complaint did not go through the facilities P&I Funds for Resident 1 (R1), R1’s funds used in these transactions did not have any type of involvement with the Licensee or staff at this facility. LPA conducted an audit of the facility P & I funds for R1 and there is no evidence of the misuse of R1’s funds or evidence that any of the debit transactions listed in this complaint were R1’s P&I funds. The debit transactions in question were funds through Tri-Counties Regional Center (TCRC) Trust Management Services (TMS) and not P&I funds through the facility. Based on the evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report printed and left with Staff. Emailed copy of report to Administrator.the state’s words, verbatim · CDSS document, Feb 26, 2023 · control 29-AS-20230125120415

Type of visit: Case Management - Deficiencies

LPA De Leon conducted a Case management- deficiency visit to the facility above on 02/26/2023 at 1:15 pm. LPA met with Nereida Leal and explained the purpose of the visit. LPA conducted an audit on 02/01/2023 of the facilities P&I funds for R1 during a complaint investigation # 29-AS-20230125120415 in which some deficiencies were found that did not pertain to the complaint allegation and are being addressed on this case management visit. The facility provided LPA a copy of R1’s LIC 405 Record of Residents Safeguarded Cash Resources and a handwritten ledger of funds used for movie tickets. The receipts were not provided for these transactions of $3.95 for movie tickets. R1’s Resident Fund Management Service (RFMS) statement was reviewed and not all receipts for debits listed were provided. The statement and balances were accurate on these forms but not all receipts were provided. The staff interview revealed the facility does not keep any P&I funds at the facility and they are kept at the business office in San Luis Obispo, CA. The facility had to request the records from the business office to provide to LPA. The facility must provide the receipts to the business office which in turn provides them to the corporate office and if the Administrator or facility want a copy of any of the receipts, they must request a copy from the corporate office. The property purchased on R1’s RFMS statement between 07/26/2019-03/22/2022 was not all listed on the LIC 621 Resident Personal Property and Valuables Statement. Administrator did update the form and listed all property for R1 and provided a copy of the up-to-date LIC 621 to LPA by email later that day. The audit did not reveal any misuse of R1’s funds but it did reveal regulation deficiencies on record keeping of receipts and providing the LPA the requested records upon demand during normal business hours. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed and left with Staff. Emailed copy of report to Administrator.the state’s words, verbatim · CDSS document, Feb 26, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80026(h)(1) · Plan of correction due date: Mar 6, 2023

(h)...(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. This requirement was not met as evidenced by: Based on record review and audit of P&I funds the licensee did not comply with the regulation above supporting receipts were not provided for all transactions listed on the LIC 405, handwritten ledger, or the RFMS statement which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 26, 2023

Plan of correction: Administrator agreed to work with business office to provide the facility with all the receipts for the residents P & I Cash and Account funds debits/credit transactions. All staff that handled P&I funds must be trained, read, review, and abide by regulation 80026 provide a copy of staff signatures that participated to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR80070(d) · Plan of correction due date: Mar 6, 2023

(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement was not met as evidenced by: Based on record review the licensee did not comply with the above regulation the facility was unable to provide all the records requested by the LPA on 02/01/2023 visit which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 26, 2023

Plan of correction: Administrator with work with corporation so the facility can provide CCL with requested documents on demand during normal business hours. Train all staff, read, review, and abide by regulation 80070 and provide copy of staff signatures to CCL.

Allegation investigated: Resident was provided additional medication without notification to Responsible Party. Facility staff did not communicate promptly with resident's responsible party.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. Administrator was not available. LPA met with Ricardo Navarro Back-up to Administrator and explained the purpose of the visit. LPA’s Jeffries and Chaves conducted the initial 10-day complaint visit on 05/14/2021, collected records and interviewed staff. LPA De Leon conducted interviews with staff on 10/10/2022 at 11:47am, 10/11/2022 at 10:46am, 10/13/2022 at 10:18am and 11:28am and 10/14/2022 at 12:04pm. LPA interviewed witnesses on 04/11/2022 at 12:14pm, 10/13/2022 at 11:53am and 4:31pm. On the allegation: Resident was provided additional medication without notification to Responsible Party. LPA conducted interview with W1 and S1 which revealed that R1 Substantiated was prescribed a new medication and staff failed to notify the POA of Health Care for R1. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation Facility staff did not communicate promptly with resident's responsible party. LPA conducted interviews with staff and witness which revealed a Power of Attorney for Healthcare naming 2 POA’s in order of preference and succession. Facility was notifying W2 but failed to notify W1 on several occasions regarding R1 and failed to notify W1 before informing W2. Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to the Administrator. that were not received. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Resident did not receive timely medical care. LPA interviewed W2 which revealed the facility did seek timely medical attention for R1 on several occasions. Interviews with staff revealed timely medical attention was sought for R1 on all occasions when R1 required medical care. Records reviewed did not reveal any mention of not seeking timely medical attention. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Resident not accorded privacy while in care. LPA interviewed staff and witness which revealed that all residents have a private room and staff give privacy to all residents in care. W1 stated that S1 did not provide privacy on a visit. S1 did approach R1’s room and introduced S1 self and asked if anyone had any questions that S1 was available. S1 left the doorway of R1’s room and returned to the living area where other staff and residents were present. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. On the allegation: Facility failed to meet resident's needs. Based on staff and witness the facility has always been able to meet R1’s needs. R1 does have health issues and R1 has been hospitalized for medical reasons and medical attention was always given in a timely matter to R1. R1’s hospital discharges were done with R1 returning back to the facility or to skilled nursing then back to the facility when needed. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. Continued 9099-C On the allegation: Facility did not follow proper Covid-19 social distancing protocols. LPA interviewed staff and witness which revealed staff, facility and visitors were following the proper Covid-19 Social distancing protocols at the facility. Records revealed sign-in, symptoms screening and temperature checking before any visitors were allowed in the facility. The facility did close visiting based on Governors orders and re-opened visitation when allowed and all requirements were met. The facility was not allowing in-person visitation during December of 2020-January of 2021 due to an outbreak at the facility and by public health officer orders. When the facility was able to open visitation all required procedures and protocols were being followed. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report emailed to the Administrator.the state’s words, verbatim · CDSS document, Oct 14, 2022 · control 29-AS-20210513123904

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 21, 2022

(a)...(8)To have their representatives regularly informed by the licensee of activities related to care...This requirement was not met as evidenced by: Based on interviews and record review the licensee did not comply with the regulation above R1’s POA W1 was not notified prior to W2 and W1 was not notified of a new medication which possess a potential Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2022

Plan of correction: Licensee agreed to train all staff in Personal Rights of Residents regulation 87468, 87468.1 and 87468.2, send up to date LIC 500 and all staff signatures for training to CCL.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) De Leon conducted a case management visit to the facility above due to a complaint investigation #29-AS-20210513123904 revealing a deficiency that was not part of the complaint allegations. Administrator was not available. LPA met with Back up to Administrator Ricardo Navarro and explained the purpose of the visit. According to the medical records of R1, R1 had two emergency room visits and a hospital admission in January 2021 that was not reported the Community Care Licensing (CCL) which is a requirement for facility reporting. Exit interview conducted, deficiency cited, copy of report and appeal rights given.the state’s words, verbatim · CDSS document, Oct 14, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 21, 2022

(a)...(1)... (D)Any incident which threatens the welfare, safety or health of any resident,...This requirement was not met as evidenced by: Based on record review the licensee did not comply with the above regulation Staff did not report two ER visits to CCL which possess a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2022

Plan of correction: Licensee with train all staff on Regulation 87211 reporting requirements and send in an up to date LIC 500 and all staff signatures for training completed to CCL.

Allegation investigated: Staff are not adequately trained

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings of the complaint allegations. LPA met with Administrator and explained the purpose of the visit. LPA De Leon conducted the initial complaint visit on 09/17/2020 at 1:09 PM -1:52 PM and interviewed staff. LPA conducted interview with Witness on 09/18/2020. LPA conducted additional interviews with staff on 10/29/2020 and 11/12/2020. LPA requested the following documentation on 09/17/2020: Resident Roster, Resident ANS or IPP's, residents LIC 602A Medical Assessments, Resident Face Sheets with ID and Emergency Information, Copy of facility emergency plan LIC 610E, TCRC QA's and Service Coordinator's name and phone number, staff roster with telephone numbers, Continued 9099-C Substantiated staff schedules for September 2020 and all Staff training records for initial or annual training Sept 2019-Sept 2020. LPA received documentation on 09/18/2020, 09/23/2020, 10/13/2020, 11/05/2020, 11/06/2020 and 11/09/2020. LPA reviewed all documentation on 07/12/2022 at 2:00 PM. On the allegation: Staff are not adequately trained. LPA conducted interviews with staff, requested and reviewed documentation which revealed the staff did not have adequate dementia training to meet the needs of R1. Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiency cited, copy of report emailed to Administrator. LPA received documentation on 09/18/2020, 09/23/2020, 10/13/2020, 11/05/2020, 11/06/2020 and 11/09/2020. LPA reviewed all documentation on 07/12/2022 at 2:00 PM. On the allegation: Staff does not prevent inappropriate interactions between residents. LPA interviewed staff which revealed staff do intervene with Resident 1 (R1) when R1 is having behaviors issues with other staff and residents. Staff interviews revealed R1’s diagnosis is worsening, R1 acts fast and staff have been unable to intervene in time when incidents have occurred, therefore this allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report emailed to Administrator.the state’s words, verbatim · CDSS document, Jul 14, 2022 · control 29-AS-20200910110658

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87707(a)(2)(A)(1-6) · Plan of correction due date: Jul 18, 2022

(a)...(2)...(A)...training topics shall be covered annually, and all topics shall be covered within a three-year period (1-6)...: This requirement was not met as evidenced by: Based on interviews and record review the licensee did not comply with the above regulation as staff did not have dementia training which poses an immediate health,Personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Jul 14, 2022

Plan of correction: Licensee/Administrator agree to review regulation 87707 and provide required dementia training on all topics that have not been covered in the past 3 years to all staff as required by regulation, proof of training and all staff signatures required to clear POC.

Allegation investigated: Resident's files are inaccurate.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings on the complaint allegation. LPA met with Back up Administrator Kathyrine Valdez and explained the purpose of the visit. LPA De Leon conducted the initial complaint visit on 09/17/2020 at 1:09 PM -1:52 PM and interviewed staff. LPA conducted interview with Witness on 09/18/2020. LPA interviewed additional staff on 10/29/2020 and 11/12/2020. LPA requested the following documentation on 09/17/2020: Resident Roster, Resident ANS or IPP's, residents LIC 602A Medical Assessments, Resident Face Sheets with ID and Emergency Information, Copy of facility emergency plan LIC 610E, TCRC QA's and Service Coordinator's name and phone number, staff roster with telephone numbers, staff schedules for September 2020 and all Staff training records for initial or annual training Sept 2019-Sept 2020. Substantiated LPA received documentation on 09/18/2020, 09/23/2020, 10/13/2020, 11/05/2020, 11/06/2020 and 11/09/2020. LPA reviewed all documentation on 07/12/2022 at 2:00 PM. On the allegation: Resident's files are inaccurate. LPA conducted interviews with staff and witness which revealed R2 was sent to the hospital in 08/2020 without an up to date emergency face sheet that R2 was on a pureed diet. LPA observed the face sheet that was sent with resident at that time which did not reflect that R2 was on a pureed diet. LPA reviewed R2’s Hospital Discharge packet which revealed discharge diet was a regular diet and did not mention pureed diet. LPA conducted interviews that revealed the resident and staff forms were not up to date at the facility and after the 09/17/2020 complaint visit the facility staff began updating all the facility files on residents and staff. LPA requested documentation on 09/17/2020 from the facility and on 09/18/2020 LPA was sent Emergency Face Sheets for each resident in care that seemed to be up to date. The updated document for R2 did reflect R2’s pureed diet. The facility was unable to send all the requested documentation LPA requested due to the facility files not being up to date and accurate, therefore the allegation is deemed Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Administrator.the state’s words, verbatim · CDSS document, Jul 14, 2022 · control 29-AS-20200916132639

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Jul 18, 2022

(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Based on observation and record review the licensee did not comply with the above regulation. Resident files were not complete and current which poses a immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2022

Plan of correction: Licensee/Administrator agree to review all resident files and make sure they have all required forms/documents, review regulation 87506 and have all staff trained, provide proof of training and all staff signatures to CCL.

Allegation investigated: Improperly restraining resident in care Behavior modification plans are not updated to reflect current needs of resident Staff are not trained properly to meet the needs of the resident

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Back up to Administrator Kathyrine Valdez and explained the purpose of the visit. LPA De Leon conducted the initial complaint visit on 10/29/2020 and interviewed staff. LPA conducted additional interviews with staff on 11/12/2020, 12/22/2020, and 12/24/2020. LPA requested the following documentation on 10/29/2020: Resident Roster, Amended IPP for R1, any training's given to staff, staff roster with telephone numbers, staff schedules for October 2020. LPA received documentation on 11/05/2020, 11/06/2020 and 11/09/2020. LPA reviewed all documentation on 07/12/2022 at 2:00 PM. Substantiated On the allegation: Improperly restraining resident in care. LPA conducted staff interviews which revealed some staff tie R1’s wheelchair wheels so he can’t move around the facility. LPA reviewed R1’s file and R1 does not have current doctor’s orders for the postural supports being used with R1. The facility does not have any approved exceptions on file with the department for R1 and/or the postural supports being used: Wheelchair with Seat Belt, Seat Belt with PIN, and Gait Chair which are limiting R1’s abilities in using R1's hands and feet, as well as R1 is unable to quick release from the postural support being used. Based on the evidence this allegation is Substantiated at this time. On the allegation: Behavior modification plans are not updated to reflect current needs of resident. LPA interviewed staff and requested documentation. Interviews with staff revealed the facility resident and staff files were not current and up to date at the facility. LPA requested documentation on 10/29/2020 which was not provided by the facility until 6-10 days later. The documentation received on 11/05/2020-11/09/2020 was up to date at the time is was sent to the department. The facility is required to have records readily available to the LPA for inspection when requested. Based on the evidence this allegation is Substantiated at this time. The deficiency and plan of correction for this allegation is being addressed and issued on complaint number 29-AS-20200916132639. On the allegation: Staff are not trained properly to meet the needs of the resident. LPA conducted interviews with staff that revealed they have not had any dementia training, they do have online training provided but no in-person or hands-on training is being completed. LPA requested and reviewed training documentation which reveals the facility staff do not have any current dementia training. Based on the evidence this allegation is deemed Substantiated at this time. The deficiency and plan of correction for this allegation is being addressed and issued on complaint number 29-AS-20200910110658. Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Administrator.the state’s words, verbatim · CDSS document, Jul 14, 2022 · control 29-AS-20201021122125

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jul 18, 2022

(a)...(3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record...This requirement was not met as evidenced by: Based on interviews and record review the licensee did not comply with the regulation above R1 did not have any doctors orders for the postural supports and the postural supports were being used by staff to limit R1’s abilities which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2022

Plan of correction: Licensee/Administrator agreed to review all residents’ records and update any records for current LIC 602’s, Doctor’s orders and complete an exception request for each resident to the department if needed. Review and train all staff on regulation 87608. Send proof of record review, training and all staff signatures to CCL.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 05/20/2022 at 11:45 AM. LPA met with Staff Nayrani Mendoza and explained the purpose of the visit. LPA took a physical plant tour of the facility. The facility has submitted a mitigation plan to the department and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening. All documentation is kept on a clipboard and in binders. The entry station has hand sanitizer along with a thermometer and additional PPE if needed. The facility has a large activity room, a dining room for dining, and a living area, all areas are spaced to accommodate as much space as possible for social distancing. The facility has a large covered patio for resident use. All additional equipment and PPE supplies are kept in the staff office. Medications are kept in a locked medication cabinet in kitchen pantry. The staff screen residents for symptoms and temperature 1x's a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or have a temperature. Signs are posted on the front door, entry area and walls in common areas regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Continued 809-C Emergency Disaster plan is posted but is not up to date, last updated LIC 610E (10/03) signed and dated 10/01/2015, this form is required to be up to date and a new form has been released by the department. House Manager is in charge of infection control and provides training and education to staff, residents and visitors. House Manager is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 4 resident bedrooms and 2 resident bathrooms and they are disinfected after use. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. Facility has a plan in place for when and whom to notify in an outbreak or other emergencies. House Manager will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in cabinets in the staff office. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. The facility is in a current outbreak and staff do not have N95 fit testing certifications. Administrator on record is not currently the administrator of the home and no staff have a valid administrators certificate or designee form on file. Fire extinguishers are charged and inspected annually. Exit interview completed, deficiencies cited, copy of report and appeal rights emailed to Administrator/Licensee.the state’s words, verbatim · CDSS document, May 20, 2022

Allegation investigated: Resident sustained a fracture while in care due to staff failing to supervise resident. Resident's bed rails not in position resulting in resident falling.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings for the above allegations. LPA met with Administrator Kathyrine Valdez and explained the purpose for the visit. On 02/02/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Care and Supervision. It was alleged that Resident #1 (R1) sustained a fracture while in care due to staff failing to supervise R1 and R1’s bed rails not in position resulting in R1 falling. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Ruben Munoz. Continued 9099-C Unsubstantiated On 02/03/2022, from 12:20pm to 1:15pm, Licensing Program Analyst (LPA) Rachael De Leon conducted the initial complaint visit. LPA De Leon met with Nereida Leal, House Manager and explained the purpose of the visit. LPA toured and took photos of R1’s bedroom. LPA requested documentation pertinent to the investigation. LPA advised the complaint was referred to the Community Care Licensing Investigations Branch (IB) and determined further investigation was needed. Investigator Munoz conducted interviews with the Reporting Party on 02/09/2022, at approximately 11:30am; with R1’s Representative on 02/11/2022, at approximately 9:02am; with Staff #1 (S1) on 02/14/2022, at approximately 7:48am, with Staff #2 (S2) at approximately 8:36am, with Staff #3 (S3) at approximately 9:12am, with Resident #2 (R2) at approximately 9:40am; with Tri-Counties Regional Center (TCRC) Service Coordinator (SC) on 03/16/2022, at approximately 3:35pm; and with TCRC Quality Assurance Specialist (QAS) on 03/17/2022, at approximately 9:12am. Additionally, Investigator Munoz reviewed Marian Regional Medical Center Medical Records, San Luis Ambulance Medical Records, 911 audio, photos, and facility file documents related to R1. R1’s facility records revealed R1 was placed at the facility on 10/04/2018. R1’s diagnoses included severe down syndrome, non-verbal, self injurious (SIB) behaviors and osteoporosis. The pre-placement appraisal information listed R1 needs help in transferring in and out of bed, uses wheelchair, and needs special observation and night supervision as R1 sometimes gets out of bed. According to R1’s Individual Service Plan (ISP), R1 uses a wheelchair, uses bilateral arm splints for self injurious behaviors and needs assistance with toileting, eating, bathing, dressing and hygiene. According to facility staff, on 01/24/2022, at approximately 2:15am, S1 heard R1’s bed alarm signal and found R1 on the floor mat next to bed. 911 records indicate S1 called 911 at 2:31am. Per the ambulance records, R1’s bed was approximately one (1) foot off the ground with a soft mat next to the bed. R1 was transported to the hospital and diagnosed with a left femur fracture. R1 had surgery on 01/24/2022 to repair the left femur fracture. Continued 9099-C On 01/26/2022, while still in the hospital, R1’s representative noted swelling on R1’s right upper extremity and wrist deformity. An x-ray of the right forearm was obtained and was consistent with right wrist volar dislocation. On 01/28/2022, a Proximal Row Carpectomy was performed on R1’s right wrist. R1 was discharged back to the facility on 02/09/2022 with a physician’s order for bed rails. A letter of support from the TCRC SC, dated 02/09/2022, was in support of R1 using the bed rails for safety. R1 had not used a bed rail prior to the order on 02/09/2022. On 02/14/2022, Investigator Munoz took photos of R1’s bed at the facility which showed a half-bed rail, a thick floor pad next to the bed, and a lowered bed. Facility staff denied any neglect or lack of care and supervision. R1’s Representative stated R1 was not neglected and facility staff provide R1 with good care. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegations. Therefore, the above allegations are deemed Unsubstantiated at this time. Exit interview and copy of report emailed to Administrator/Licensee.the state’s words, verbatim · CDSS document, Apr 8, 2022 · control 29-AS-20220202105403

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) De Leon conducted a Case Management (CM)- Deficiencies visit to the facility above. LPA met with Administrator Kathyrine Valdez and explained the purpose of the visit. Community Care Licensing (CCL) received complaint # 29-AS-20220202105403 on 02/02/2022 and during the complaint investigation deficiencies were observed these deficiencies did not relate to the complaint allegations and therefore are being addressed on this CM visit. CCL Investigation Branch conducted the investigation. During the physical plant tour on 02/14/2022 Investigator Munoz observed the following deficiencies: During the physical plant tour the investigator took photos of the resident 1 (R1's) bedroom. Photographs show a baby monitor in the resident’s room. Staff interviews also confirmed they use baby monitors for the residents. LPA De Leon spoke with Staff at the facility and explained that baby monitors are a personal rights violation and if the facility wanted a device for residents to get help, they must comply with the regulation requirements. Staff removed baby monitors from the resident’s room and will work with corporation to provide something to residents that met the regulation requirements. During the investigation facility records were reviewed and the following were noted by the Investigator: Resident #1 (R1) has SIB and uses bi-lateral arm splints with a Dr. order dated 10/11/2018. LPA De Leon reviewed the facility record and CCL does not have an approved exception for R1 on file for the use of these on R1. The documentation reviewed for R1 shows a physician report LIC 602A dated 11/30/2021 stating R1 is total care . LPA De Leon reviewed the facility record and CCL does not have an approved exception on file for the total care of R1. Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to the Administrator/Licensee.the state’s words, verbatim · CDSS document, Apr 8, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2.(a)(1) · Plan of correction due date: Apr 12, 2022

87468.2 (a)(1)...personal privacy in accommodations,... and assistance, visits, communications, telephone conversations,... This requirement was not met as evidenced by: Based on observation the license did not comply with the above as R1 had baby monitors in their bedroom which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: Administrator agreed to read and review regulation 87468.2, train staff and sign documentation, baby monitors have been removed from facility. If the facility is going to provide any type of device for the resident it will met regulation requirements. Send documentation to CCL by 04/12/22

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(2) · Plan of correction due date: Apr 11, 2022

(a)...resident is unable to do for himself/herself...may be used under the following...(2)...shall...in a manner that permits quick release by the resident. This requirement was met as evidenced by: Based on documentation the licensee did not comply with the above as R1 is not able to release/takeoff the postural supports and an exception has not been approved by CCL which poses a potential safety and personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: Administrator agreed to immediately send documentation to CCL for an exception request for R1’s bi-lateral arm splints.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87615(a)(5) · Plan of correction due date: Apr 11, 2022

(a)...(5)Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement was not met as evidenced by: Based on documentation the license did not comply with the above as R1 had a physician report dated 11/30/2021 stating R1 was total care and no exception approval on file for R1 with CCL which poses a potential Health, Safety and Personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: Administrator agreed to immediately send documentation to CCL for an exception request for R1’s total care.

Allegation investigated: Facility interfered with resident receiving mail.

Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit at the facility above on 07/08/2021 at 10:00am. LPA met with Kathyrine Valdez, LVN back up to Administrator at the facility and explained the purpose of the visit. LPA requested the following records: Staff schedule for week of 06/19/2021- 06/25/2021, Staff roster with phone numbers, Resident 1 (R1) emergency information and contacts sheet, threee residents personal property and valuables records, Visitor sign in and out log for 05/19/2021-07/08/2021, Copy of paperwork that was served to R1 on 05/25/2021, Copy of R1's Temporary Conservator paperwork. LPA reviewed all records and conducted interviews with facility staff and witnesses. Unsubstantiated On the allegation: Facility interfered with resident receiving mail. Interviews conducted by LPA revealed the staff did not sign for any packages at the facility on 06/19/2021 and no staff checked the mail at the facility on 06/19/2021. The mail procedures at the facility have the administrator checking the mail Monday - Friday only. If a package comes on the weekend that would require a signature the administrator is notified, the staff on duty sign for the package and then staff leave it in the office for the administrator to process. There is no record to indicate the facility, the staff or R1 received a package on 06/19/2021. Postal records show the mail person left a package in the mail box at the facility address on 06/19/2021 at 2:20pm, this package was a certified letter with return receipt. The return receipt was not signed for by staff at the facility and the person that mailed the package to R1 did not receive a signed return receipt for the package sent. Interviews with Administrator's did not reveal any package left in the mail box over the weekend of 06/19-06/20, 2021. LPA did not observe the contents of the package in R1's room. R1 was served an envelope containing court documents on 05/25/2021 and those documents are present in R1's records. The facility does have a mail box at the front of the residence, it does not lock and it is accessible at the street. Staff log all residents property as it is received and LPA reviewed those log records. R1 did not have any property logged in during June 2021. The resides property logs are dated and kept in the residents files. Based on the lack of evidence the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report emailed the Administrator.the state’s words, verbatim · CDSS document, Jul 8, 2021 · control 29-AS-20210702090846