Strawberry Cottage

Allegation investigated: Staff did not assist resident in a timely manner. Staff did not provide a safe and comfortable environment for resident.

On 09/14/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit for the above allegations. LPA arrived at the facility at 10:00 a.m. and was greeted by Staff #1 (S1) who granted access. S1 called the Administrator Designee Hailam P. Taylor. Administrator David Taylor was unavailable. Hailam met LPA shortly after. Hailam contacted Administrator David Taylor via telephone and LPA explained to Administrator Designee Hailam and the Administrator David Taylor the purpose of the visit. Hailam will sign todays report. An entrance interview was conducted. At 10:15 a.m. LPA conducted a physical plant tour to ensure the health and safety of the residents in care. From 10:30 a.m. to 12:00 p.m. LPA conducted interviews with Administrator and Staff #2 (S2) over the phone. LPA conducted interviews with Administrator designee, S1 and three (3) out of six (6) residents at the facility. From 12:00 p.m. to 2:44 p.m. LPA reviewed resident records and obtained documents relevant to this investigation. (Continued on LIC9099-C) Substantiated Allegation #1: Staff did not assist resident in a timely manner. In regards to the allegation it was reported Resident #1 (R1) had an unwitnessed fall in one of the facility bathrooms and was lying on the bathroom floor without receiving assistance for 30 minutes. To investigate the allegation LPA conducted interviews with three (3) out of six (6) residents and staff #2 (S2), who was present during the incident in question. LPA interview with R1, R1 affirms they had an unwitnessed fall in the bathroom while they were attempting to get out of the bathtub after the fall they eventually were able to get up and inform S2 they had a fall. Interview with S2 corroborates R1 notified them they had a fall in the bathroom. Interview with S2 revealed they did not hear R1 have a fall and didn't realize R1 was taking a shower. Interview with various resident's revealed they have waited over a minute to an hour for assistance after pushing their call button, ringing a bell or calling out for assistance. Staff schedule revealed there is usually one staff present in the AM shift and one staff present in the PM shift for six (6) residents. Staff interview revealed if staff is assisting a resident in the shower they have to complete the shower first to then be able to attend to other residents which can take over 5 to 10 minutes. Based on interviews and record review this allegation is Substantiated at this time. Allegation #2: Staff did not provide a safe and comfortable environment for resident. In regards to the allegation it was reported that R1's mattress needs to be replaced and the bathroom R1 one uses needs a grab bar when getting out of the bathtub. To investigate the allegation LPA conducted interviews with R1, staff and conducted a physical plant tour. LPA interview with R1 revealed they believe the fall in bathroom could have been prevented had there been a grab bar on the outside of the bathtub/shower. LPA observed the bathroom in question and although the bathroom is equipped with one grab bar by the toilet and another inside the bathtub/shower, it does not have one at reach for residents entering or exiting the bathtub. Interview with staff revealed most residents shower in the second bathroom that has a walk in shower. LPA observed the second bathroom is located farthest from the residents' bedrooms. LPA's review of R1 records revealed R1 is ambulatory, however is assisted with a device to get around. In regards to R1's mattress, LPA's review of facility records revealed facility had purchase a new mattress in May 2023 - June 2023. Administrator designee stated they have rotated the mattress but may either purchase a bed topper or take R1 to pick out their own mattress. Based on interviews, record review and LPA's observation the allegation "facility needs a grab bar" is Substantiated at this time. Deficiencies cited on LIC9099-D. Exit interview conducted. Appeals Rights provided. Copy of report provided Allegation: Staff did not meet resident's needs. In regards to the allegation it was reported, R1 was denied food between 12:30 p.m.- 6:00 p.m. LPA interview with R1, R1 affirms they had asked staff #3 (S3) for food and S3 denied to serve them a meal because they did not serve between 12:30 p.m. to 6:00 p.m. Interview with staff revealed they try their best to serve meals R1 will eat and serve meals when it is requested no matter the time. Staff denies the allegation. Resident interviews state they like the food served at the facility and have not been denied food or snacks when they have asked. LPA could not find any witness to corroborate the allegation. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report providedthe state’s words, verbatim · CDSS document, Sep 13, 2023 · control 31-AS-20230908152350

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(4) · Plan of correction due date: Sep 22, 2023

(e) Water supplies and plumbing fixtures shall be maintained as follows:(4)Grab bars shall be maintained for each toilet; bathtub and shower used by residents. This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not ensure that R1 had a grab bar that allowed them to safely enter and exit the bathtub which posses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: Administrator agreed to add grab bar. Administrator will submit a picture of grab bar to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 22, 2023

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Various interviews and observation revealed that staff do not responded to the call for assistance from residents in a timely manner. This poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Sep 13, 2023

Plan of correction: Administrator is to submit to LPA a plan to ensure that Section 87468.2(a)(4) will be complied with at all times.

Allegation investigated: Staff do not ensure safety measures for resident(s) in care.

On 06/14/2023 Licensing Program Analysts (LPAs) Evelin Rios and Melissa Ruiz conducted an announced subsequent complaint visit for the above allegation. LPAs arrived at the facility at 10:00 a.m. and were greeted by staff#1 (S1) who granted access. S1 called the Administrator David James Taylor. Administrator met LPAs shortly after and informed David about the purpose of the visit. Staff do not ensure safety measures for resident(s) in care. It is alleged a staff #2 (S2) dog chased resident#1 (R1) to their room. To investigate this allegation LPA Rios conducted initial interviews with residents and staff on 05/02/2023 from 2:00 p.m. to 2:50 p.m. and from 5:45 p.m. to 6:32 p.m. LPA reviewed resident records and obtained documents relevant to this investigation. On 05/03/2023 Licensing Program Analyst (LPA) Rios conducted a follow-up interview with resident#1 at 10:21 a.m. (LIC9099-C continued on to next page) Unsubstantiated At 10:36 a.m. LPA reviewed and obtained further documents relevant to this investigation. Interviews and documentation revealed S2 has a service or assistance animal they bring to work. Interviews with staff and residents are not consistent on the behavior of the animal. LPA Rios reviewed PIN 17-05-ASC SERVICE AND ASSISTANCE ANIMALS. Based on interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 14, 2023 · control 31-AS-20230427111039

Allegation investigated: Facility did not arrange, or assist in arranging, for necessary medical care for resident(s). Facility did not arrange, or assist in arranging, for transportation of resident(s) to and/or from hospital.

On 06/14/2023 Licensing Program Analysts (LPAs) Evelin Rios and Melissa Ruiz conducted an unannounced complaint visit for the above allegations. LPAs arrived at the facility at 10:00 a.m. and were greeted by staff#1 (S1) who granted access. S1 called the Administrator David James Taylor and met with LPA shortly after. LPAs informed him about the purpose of the visit. Allegation #1:Facility did not arrange, or assist in arranging, for necessary medical care for resident(s). It is alleged resident#1 (R1) has requested assistance with receiving a consistent replenishment of portable oxygen which facility has failed to obtain and furthermore has failed to make arrangements for R1 to see a physician per R1s request. To investigate this allegation LPA interviewed residents and administrator from 11:00 a.m. to 12:00 p.m. Interview with R1 revealed that about three months ago they had requested to see a physician for a health concern and according to R1, the administrator did not assist them with arranging the appointment. (LIC9099-C Continued on next page) Substantiated It is alleged resident #1 (R1) has to purchase their own food because the facility does not serve good quality meats and there is never any milk, eggs, and/or coffee at the facility. To investigate this allegation LPA toured the kitchen and viewed the stored items in two out of two refrigerator, one deep freezer and reviewed the meal calendar. LPA observed frozen meat from the butcher section and prepaid meats. LPA also observed eggs, milk and eggs in the refrigerator and coffee in the kitchen cabinet. Based on observation this allegation deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided. LPAs interview with the administrator revealed the administrator was away on vacation for the month of May and this was confirmed by LPA's previous visit made on 05/03/2023. Administrator confirmed no appointments have made due to issues with R1's insurance. Administrator states they are not aware of any staff arranging appointments for R1. Furthermore in the interview with R1, R1 stated they do not feel comfortable or safe going to appointments without enough portable oxygen. Lastly interview with R1 revealed that they recently missed an appointment due to an appointment at 1:30 p.m. and staff arriving to the facility to pick them up at 1:15 p.m. Administrator also confirmed staff arrived between 1:13 p.m. -1:15 p.m. Based on interviews and record review this allegation is Substantiated. Allegation #2: Facility did not arrange, or assist in arranging, for transportation of resident(s) to and/or from hospital. It is alleged that on 5/28/2023 R1 was discharged from the hospital and no transportation or arrangement was made to have him return to the facility. To investigate this allegation at approximately 11:00 a.m. LPA Rios conducted interviews with residents and Administrator. At 12:00 p.m. LPA reviewed resident records and obtained documents relevant to this investigation. Records revealed R1 was discharged from the hospital at 1:48 a.m. R1 stated the hospital was trying to contact the facility repeatedly but were unable to reach anyone. R1 had to make arrangements with a friend and did not arrive to the facility until approximately 7:30 a,m, Furthermore Administrator confirmed the hospital had contacted his personal phone number while he was on vacation and designee was out of town. Based on interviews and record review this allegation is Substantiated. Deficiencies cited (refer to 9099-D).Copy of this report and appeals provided.the state’s words, verbatim · CDSS document, Jun 14, 2023 · control 31-AS-20230608131051

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 30, 2023

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure that R1 made it to a scheduled appointment on one occasion which posses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 14, 2023

Plan of correction: Licensee shall read cited regulation and submit a statement of understanding to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(6) · Plan of correction due date: Jun 30, 2023

87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure that timely or adequate transportation was provided for R1 upon discharge from the hospital. This posses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 14, 2023

Plan of correction: Licensee shall conduct training for all staff, training shall specifically include arranging transportation for medical appointments, medical emergencies, or outings. Proof of training and any training materials shall be submitted by the POC due date.

Allegation investigated: Staff failed to administer resident's medication as prescribed.

At 10:00 a.m., Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced subsequent complaint visit. LPA was greeted by staff and later met with Licensee, David Taylor. The purpose of the visit was explained, and an entrance interview was conducted. Allegation: Staff failed to administer resident's medication as prescribed. On 5/5/2022, LPAs Ruiz and Martinez conducted an initial visit. During this visit, LPAs conducted a random medication count for R1 from 11:30 a.m. – 12:00 p.m. and two medications Baclofen and Quetiapine Fumarate (Seroquel) were observed to be inconsistent with the medication instructions. The medication Baclofen was to be administered 3 times a day, and there were three separate bubble packs for morning, noon, and night. LPAs observed 2 pills in the a.m. packs for 5/5/22, and 5/3/22 and the Medication Administration and Record log (MAR) was signed by a staff member indicating that the medication was given on said dates. In addition, from 4/26 – 4/30, Quetiapine Fumarate (Seroquel), which was to be administered once at night, was administered using the May pack because some of the pills were missing for the month of April. Afterwards, the licensee contacted the pharmacy to replace the missing pills. MARs did not have a staff signature on 4/23, 4/24, and 4/25. Due to record review and LPA observation, the allegation above is substantiated. Deficiency issued per CCR, Title 22. Appeal rights issued. Report signed and delivered. Substantiated All residents stated that they get along with staff and the staff have never spoken to them inappropriately. Due to interviews conducted, there is insufficient evidence to prove the allegation may or may not have occurred, therefore it is unsubstantiated at this time. Allegation: Facility has not provided transportation to medical appointment. It is alleged that the Licensee/staff did not provide transportation for R1. LPA interviewed the Licensee on 5/5/23, and he stated that they never refuse to transport any resident in care and do provide transportation to all residents for different outings, but specifically medical visits. The licensee also stated that they do not charge the residents for transportation, even though it is outlined in their Admission Agreement. The licensee stated that R1 had asked the staff to transport them to the lab to do a TB test, as a walk in however, it was insufficient notice to staff and/or licensee. Additionally, on 6/13/23, LPA reviewed R1’s admission agreement, which states that “All transportation arrangements require a minimum of 48-hours’ notice”. Allegation: Resident is being charged extra fees. On 5/5/22, an interview with R1 was conducted at 10:35 a.m. and R1 stated that the facility charges them around $4.00 for every Instacart delivery or service fee for using the application. On 5/5/22, an interview with the Licensee revealed that R1 does prefer to have their own personal groceries shopped and delivered with Instacart. The licensee also stated that Instacart uses R1’s EBT card for the groceries, however EBT does not cover tips, service fees, checkout bag fee, or beverage container fees. These additional fees are covered by the licensee’s own personal card, since the licensee places the orders for R1. In addition, on 6/13/23, LPA Ruiz reviewed various receipts for Instacart that reflect both EBT and Mastercard payment methods used for the groceries. The Mastercard charges range from $3.75, $5.32, $3.21, $4.22 and so forth. Due to interviews conducted and record review, the allegation above is deemed unsubstantiated. No deficiencies issued. Report signed and delivered. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 13, 2023 · control 31-AS-20220429094057

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 16, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on LPA observation and record review, two medications for R1 were not issued as prescribed and the MARs was not filled out correctly, due to staff not signing or signing in advance which poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2023

Plan of correction: The licensee shall hire a State approved vendor to train all staff and licensee on medication assistance. Licensee shall submit proof of requesting/booking training by the POC due date and by 6/23/23, Licensee shall submit verification of training completed for all staff.

Allegation investigated: Licensee does not dispense medication as prescribed to resident(s) in care. Licensee does not assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. Staff do not safeguard resident's personal property. Resident's mattress is in disrepair.

On 05/03/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above allegations. LPA arrived at the facility at 10:00 a.m. and was greeted by staff #1 (S1) who granted access. Ricky Desahagun called the facility as LPA was checking in and LPA informed Ricky about the purpose of the visit. Ricky met LPA shortly after. At 10:21 a.m. LPA conducted a follow-up interview with one out of six residents. At 10:36 a.m. LPA reviewed and obtained further documents relevant to this investigation. Allegation #1: Licensee does not dispense medication as prescribed to resident(s) in care. It is alleged Licensee has withheld prescribed medication from R1. To investigate this allegation on 05/02/2023 LPA observed Ricky count medication and LPA compared the count with Centrality Stored Medication Logs and Medication Administration Records (MAR). (Continued on LIC9099-C) Substantiated (LIC9099-C Continued) LPA observed two prescribed medications listed on Centrally Stored logs with Date Started 05/01/2023 for R1. On 05/02/2023 Ricky could not provide medications and revealed medications are not in the facility. Interview with Ricky on 05/02/2023 revealed the Centrally Stored Medication Log is created and provided by the pharmacy and medication was previously provided but has not been delivered by the pharmacy. Ricky could not explain why the Date Started is filled in with 05/01/2023 when the medication is not in the facility. On 05/03/2023 at 11:12 a.m. interview with Ricky revealed one medication for R1 was ordered on 05/01/2023 should be delivered in 2-3 days for R1. Based on observation and interviews, the allegation mentioned above is Substantiated at this time. Allegation #2: Licensee does not assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. It is alleged Licensee did not arrange for follow-up appointments for R1. To investigate this allegation LPA reviewed facility's Program: Resident Handbook Of House Rules which indicates the facility is responsible for ALL doctor's and medical appointments, whether routine or in an emergency. During an Emergency Room (ER) visit on 04/20/2023 and 04/24/2023 R1 received instructions to have follow-up appointments with primary doctor. R1 notified Administrator David of instructions given by ER. A follow-up appointment was not determined to be made promptly. Subsequently it was determined an appointment was made after a third visit to the ER on 05/01/2023. Based on interviews and record review, the allegation mentioned above is Substantiated at this time. Allegation #3: Staff do not safeguard resident's personal property. It is alleged mail addressed to R1 had disappeared from where they were originally observed to be. On 05/02/2023 at 05:45 p.m. LPA observed a letter addressed to R1 peeking out from behind a propped-up staff calendar on the administrator’s desk. Interviews with two out of two staff revealed mail is gathered and placed on top of a small fridge located in the office to be handed out to residents. Staff could not explain why a letter would be behind a staff calendar. Based on observation and interviews, the allegation mentioned above is Substantiated at this time. (Continued on LIC9099-C) (LIC9099-C Continued) Allegation #4: Resident's mattress is in disrepair. It is alleged a mattress for resident #3 (R3) is causing bruising on R3’s back. To investigate this allegation on 05/03/2023 LPA and Ricky conducted a physical plant tour of four out of four bedrooms and observed four out of six mattresses. LPA observed R6’s mattress to have a tear on the side of the mattress. LPA observed R3’s mattress to be discolored, have a brownish color stain, and have tears on the bottom side of the mattress. LPA observed Resident #4’s (R4) mattress to have tears on the top of the mattress. Based on observation and interviews, the allegation mentioned above is Substantiated at this time. Deficiencies issued per CA Code of Regulations, Title 22 (refer to LIC9099-D). Report signed and delivered. Exit interview conducted.the state’s words, verbatim · CDSS document, May 3, 2023 · control 31-AS-20230427111039

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87645(a)(4) · Plan of correction due date: May 5, 2023

(a) A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following:(4)The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on document review and interviews the Licensee did not ensure R1 was administered medication as prescribed. This poses an immediate health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Licensee shall submit receipt for medication not located in facility and a picture of medication taken at the facility. A copy of the receipt and medication shall be provided to CCL/LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(15) · Plan of correction due date: Jun 8, 2023

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(15)To send and receive unopened correspondence in a prompt manner. This requirement is not met as evidenced by: Based on interviews and observation the Licensee did not ensure R1 received their correspondence in a prompt manner. This posed a potential health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Licensee shall submit a statement of understaning on cited regulation 87468.1(a)-(b) and provide a copy in writing of the process facility will use to promptly proved unopen mail to residents. A copy of statemen and process shall be provided to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(A) · Plan of correction due date: Jun 8, 2023

(a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply:(3) ...the licensee shall assure provision of:(A)A bed for each resident...appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress...This requirement is not met as evidenced by: Based on interviews and observation the Licensee did not ensure 4 out 6 residents had good spring, clean and comfortable mattresses. This poses a potential health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Licensee has agreed to purchase new mattress for the residents that are not provided one by other means. Licensee will submit to LPA a receipt and picture of new mattress purchased for residents identified to need one to LPA by POC due date.

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

Type of visit: Case Management - Deficiencies

On 05/03/2023 in conjunction with a subsequent complaint visit control number 31-AS-20230427111039, Licensing Program Analyst (LPA) Rios did an unannounced CASE MANAGEMENT - Deficiencies visit. LPA met with Administrator Designee Ricky Desahagun, LPA spoke with Administrator David Taylor over the phone informed them of the purpose of the visit. On 05/02/2023 during interviews with staff and residents it was revealed resident #3 (R3) had a fall some time in the week of 04/09/2023. Interview with Ricky on 05/03/2023 revealed a nurse from Home Heath had seen R3 who took her vitals and reported no issues. A physical therapist had also visited the resident but informed facility R3 could not continue because resident was complaining of pain when moved. According to Ricky, physical therapy was placed on hold until R3 is examined to determine they are fine to continue with physical therapy. LPA advised Ricky resident needs to receive medical attention to rule out serious injury from fall. Ricky called the Administrator David who informed Ricky, R3 is in hospice. Ricky could not provide to LPA name of hospice or date of admission to hospice for R3. On 05/03/2023 LPA made a follow-up visit to confirm if resident had received medical attention. Administrator David informed LPA R3 was seen by Home Health and is being placed on hospice. Administrator David could not provide name of Hospice or date of admission to hospice. LPA again advised Ricky and David to call 911. Ricky called 911 at 10:55 a.m. and ambulance arrived at 11:38 a.m. to transport R3 to the hospital. On 05/02/2023 LPA observed Ricky count medication and LPA compared the count with Centrality Stored Medication Logs and Medication Administration Records (MAR). LPA observed pill counts were over the total quantity number of pills listed on the prescribed medication bottles for resident #2(R2) and resident #6(R6). LPA spoke with the Administrator David over the phone and Administrator explained, “They shouldn’t do that, I’ve trained them.” In reference to staff pouring pills from one bottle to another. (LIC809-C Continued) (Continued Lic809-C) Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D). Copy of this report provided, appeal form given. Exit interview conducted.the state’s words, verbatim · CDSS document, May 3, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Jun 8, 2023

(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement is not met as evidenced by: Based on document review and interviews the Licensee did not call 911 for R3 when they were notified R3 had a fall in the facility and R3's health condition changed. This poses a potential health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Licensee will provide to LPA copy of written instructions left to staff: that they are not to wait to call 911 when they witness or suspect an injury to residents in care. Licensee shall also make an addendum to their Program to include instructions above and provide a copy to CCL to be added to facility file by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(5) · Plan of correction due date: May 5, 2023

(h)The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on observation and interviews the Licensee did not ensure prescribed medication was kept in their original containers for two out of six residents. This poses a potential health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 3, 2023

Plan of correction: Licensee will identify medication that is over quantity and ascertain from pharmacy what was the expiration date for the previous medication. Staff will complete LIC 622 for all future medication for all residents. Licensee will email completed LIC 622 for all residents in care by POC due date.

Type of visit: Case Management - Deficiencies

In conjunction with complaint visit control number 31-AS-20230427111039, Licensing Program Analyst (LPA) Rios did an unannounced CASE MANAGEMENT - Deficiencies visit. LPA met with Licensee Designee Ricky Desahagun, LPA spoke with Licensee David Taylor over the phone informed him and Ricky the purpose of the visit. During the visit it was observed that staff #2 (S2) was working in the facility without being associated with this facility. Record review revealed S2 does have fingerprint and background clearance, but is not associated to this facility. Licensee stated S2 has worked in the facility on and off whenever coverage is needed. Interviews with residents and staff corroborate S2 has worked in the facility and provided assistance to residents. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D). A civil penalty was assessed and given (refer to LIC421BG). Copy of this report provided, appeal form given. Exit interview conducted.the state’s words, verbatim · CDSS document, May 2, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 3, 2023

All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) ....This requirement is not met as evidenced by: Based document review and interviews the Licensee did not ensure that S2 was associated to the facility. This poses an immediate health and safety or personal rights risk to cresidents in care.the state’s words, verbatim · CDSS document, May 2, 2023

Plan of correction: Licensee shall submit evidence of transfer request or completion of transfer/ association of staff #2 to this facility. A copy of the receipt shall be provided to CCL/LPA by POC due date.

Allegation investigated: Staff fail to provide aid with daily living Staff failed to address resident's change in medical condition

Licensing Program Analyst (LPA) Shira Stamps conducted an unannounced subsequent complaint visit for the above allegations. Entrance interview conducted with the Administrator. On 9/6/22, LPA collected documents and on 9/16/22 LPA conducted interviews and collection additional documents. Allegation: Staff fail to provide aid with daily living It is alleged that resident one (R1) is being neglected and not receiving proper care. It is alleged that R1’s issues with the toes are getting worse and staff do not clean R1’s toes or R1’s seat, and R1 believes that wound care is needed, and that R1 wants to be transferred to a new facility. Based on document review the facility provides basic services to all residents in care, and R1 had an assisted living waiver program service plan. R1 was also receiving hospice services. CONTINUED... Unsubstantiated A review of the hospice care notes from 5/05/20-6/25/20 found that hospice documented and provided services to R1, such as bed baths, incontinence needs, transfers with Hoyer lift, education of pressure ulcers and pain medication administration times, and developed plans for repositioning. R1’s refusal of assistance with daily living was also documented on the hospice care notes. On 6/12/20, R1 was discharged from hospice services because they could no longer meet R1’s needs. On 6/16/20, R1 was taken to the hospital for a foot pressure sore that had been treated by hospice care, and after an assessment from the doctor it was recommended that R1 would benefit from a rehab center due to R1’s history of abusing pain medications. Based on document review, it was found that the facility and hospice provided assistance with daily living to R1, and the facility completed the reappraisal in a timely manner, therefore the allegation, “Staff fail to provide aid with daily living” is deemed unsubstantiated. Allegation: Staff failed to address resident's change in medical condition It is alleged that R1 was admitted to Hospice Care on 4/06/20, and that R1 is now no longer receiving Hospice Care and R1 was not informed. An incident report received 5/9/20, was reported to Community Care Licensing (CCL) indicated Hospice Care was notified of R1’s fall and hospice was looking into alternative treatments or alternative facility types for R1 due to the increased demand for pain medication. Based on document review, it was found that R1 was discharged and notified by the hospice agency on 6/12/20 that Hospice Care services could no longer meet the needs of R1, and it was recommended by Hospice that R1 go to a different type of facility such as a pain clinic due to R1’s increased demand for pain medications. It was noted that Hospice explained the plan to R1 and R1 verbalized understanding. Based on document review, R1 was properly notified of changes, therefore the allegation, “Staff failed to address resident's change in medical condition,” is deemed unsubstantiated. Exit interview conducted. Copy of report delivered to Administrator.the state’s words, verbatim · CDSS document, Apr 14, 2023 · control 31-AS-20200618160904

Allegation investigated: Resident is being illegally evicted Facility did not release resident's personal belongings

Licensing Program Analyst (LPA) Shira Stamps conducted an unannounced subsequent complaint visit for the above allegations. Entrance interview conducted with the Administrator. On 9/6/22, LPA collected documents and on 9/16/22 LPA conducted interviews and collection additional documents. Allegation: Resident is being illegally evicted It is alleged that the resident (R1) was rushed to the hospital, and the facility would not accept R1 back into the facility. Based on record review, it was found that R1 was discharged and notified on 6/12/20 that Hospice Care services could no longer meet the needs of R1, and it was recommended by Hospice that R1 go to a different type of facility such as a pain clinic due to R1’s increased demand for pain medications. It was noted that Hospice explained the plan to R1 and R1 verbalized understanding. On 6/16/20, an incident report was sent to Community Care Licensing (CCL) stating that R1 wanted to go to the hospital because of foot pain that was being treated by Hospice Care. CONTINUED... Unsubstantiated 911 arrived and R1 was assessed and taken to the hospital. The incident report states later that evening the doctor called the Administrator and informed him that R1 does not belong in a Residential Care Facility for the Elderly (RCFE) home anymore, and it was suggested that she would benefit from a rehab program. Interviews indicated the social worker at the hospital would place R1 in a medical facility. LPA was unable to obtain documentation from the hospital stating R1 needs a higher level of care. On 6/14/20, the facility completed a reappraisal stating the resident should be returned to a higher level of care as recommended by Hospice and the Hospital. On 6/17/20, the Administrator informed R1’s representative party that R1 had been moved to a medical facility by the hospital due to the need of more care. Based on interviews it was indicated that the hospital recommended and placed R1 into a facility with a higher level of care. Interviews and documentation do not show that the facility refused to accept R1 back into the facility. Therefore, due to lack of supportive evidence the allegation, “Resident is being illegally evicted” is deemed unsubstantiated. Allegation: Facility did not release resident's personal belongings It is alleged that R1 was unable to get their belongings after being rushed to the hospital. Based on document review, the facility sent a letter on 6/26/20 to R1’s representative party requesting that they pick up R1’s personal belongings. Document review also found that R1’s representative party signed a statement confirming that all of R1’s personnel belongings were picked up on 6/29/20. Therefore, based on document review, the allegation, “Facility did not release resident’s personal belongings,” is deemed unsubstantiated. Exit interview conducted. Copy of report delivered to Administrator.the state’s words, verbatim · CDSS document, Apr 14, 2023 · control 31-AS-20200624133943

Type of visit: Required - 1 Year

On 8/30/22 at 12:15 p.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff member and was allowed entrance. LPA observed covid-19 signage, hand sanitizer, and a visitor sign in log. LPA later met with the Administrator and advised the Administrator to remind staff to conduct infection control protocols for every visitor. LPA explained the purpose of the visit and an entrance interview was conducted. LPA initiated a physical plant tour at 12:35 p.m. Facility is a Residential Care Facility for the Elderly which was licensed for six (6) residents of which five (5) may be non-ambulatory and one (1) may be bedridden. Facility has been approved for a hospice waiver for two (2). LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area and has a date of purchase of 2/7/2022. Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a comfortable temperature of 76 degrees Fahrenheit. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. There is a clean covered shaded area in the back yard and there are no bodies of water. No deficiencies issued during today’s visit. Report was signed and delivered by Administrator and an exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 30, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pitz conducted an unannounced infection control visit on this day. LPA was greeted upon entry and screened for COVID-19 symptoms. LPA toured the facility with administrator David James Taylor and confirmed that they do have an approved mitigation plan on file. LPA utilized the infection control domain of the RCFE inspection tool to verify that the facility was in compliance with various aspects of the mitigation plan, including but not limited to: screening visitors, having ample handwashing/ sanitizing supplies on site, having adequate PPE on site, having signs posted throughout the facility to remind residents and staff of various Covid precautions. LPA did not note any concerns at the time of visit. Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.the state’s words, verbatim · CDSS document, Jul 15, 2021