Summer House at Ladera Heights

Allegation investigated: Staff are not keeping medications in a safe and locked location. Staff are not keeping dangerous items in a safe and locked location.

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, November 07, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with staff Chris Gaytos and Mayet Neri. LPA spoke to Licensee Mark Loo via telephone. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: Interviews conducted with staff 1-3 (S1-S3), residents 1-3 (R1-R3), and witness 1 (W1) LPA Bunker was unable to interview resident 4 (R4), R4 was sleeping and is hard of hearing. LPA Bunker asked questions relevant to the nature of the complaint. Staff Mayet and LPA Bunker toured the entire facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visits. LPA Bunker reviewed residents' medication records in the facility-locked cabinet in the hallway. LPA observed resident knives in a locked cabinet in the kitchen inaccessible to residents. LPA Bunker requested copies of supporting documents. See continued LIC9099-C page 2 Unsubstantiated See continued LIC9099-C page 2 Allegation #1: Staff are not keeping medications in a safe and locked location. LPA Bunker conducted interviews with staff 1-3 (S1-S3), residents 1-3 (R1-R3), and witness 1 (W1) regarding the allegation that, on October 31, 2023, resident medications were stored in a locked cabinet in the hallway, and medication is consistently secured. S1-S3, R1-R3, and W1 unanimously affirmed that staff diligently safeguard residents' medications at all times, maintaining them in a secure, locked place. In summary, all parties interviewed denied the allegation. Allegation #2: Staff are not keeping dangerous items in a safe and locked location. LPA Bunker interviewed staff 1-3 (S1-S3), residents 1-3 (R1-R3), and witness 1 (W1) concerning the alleged allegation of dangerous items not being stored in a secure, locked location. According to their statements, knives in the facility are stored in a locked cabinet in the kitchen, ensuring that they are inaccessible to residents in care. S1-S3, R1-R3, and W1 consistently denied the allegation. The investigation consisted of the following: Interviews with staff 1-3 (S1-S3), residents 1-3 (R1-R3), and W1, who all attested that medications are consistently stored in a safe, locked location. Staff confirmed that they unlocked the medication cabinet to dispense medication to residents, promptly locking it afterward. Medication is never left unattended in the kitchen at eye level. S1-S3 emphasized that medications are appropriately labeled and maintained in compliance with regulations. Medications are securely locked and inaccessible to residents. The same rigorous safety measures apply to dangerous items, which are kept in a locked kitchen cabinet, with kitchen knives only taken out for cooking and food preparation. S1-S3, R1-R3, and W1 affirmed that residents do not have access to the kitchen area, ensuring their safety. Staff takes great care to meet residents' needs, and S1-S3 emphasized their training and competence in delivering the necessary services. They are committed to preventing residents from harm, injury, and danger. R1-R3 expressed their satisfaction with the staff's kindness and quality of care, stating they are content living at the facility. S1-S3, R1-R3, and W1 collectively denied the allegations. See continued LIC9099-C page 3 See continued LIC9099-C page 3 Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-Cs provided to the facility staff. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 11-AS-20231102124719

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: POC

On 7/27/23, Licensing Program Analyst (LPA) Felisa Shirley arrived to follow-up on deficiencies issued during visit on 7/21/23. LPA was met by staff Chris Gaytos, and the purpose of today’s visit was explained. The following deficiencies were observed and cited for on 7/21/23: -At 09:55 am LPA took hot water temperate in facility kitchen and noted that it was 120.8 F. -At 09:57 am LPA observed that cabinet in kitchen which held medication was not locked. -At 10:06 am LPA observed a bottle of Lysol under bathroom sink, cabinet did not have a lock. -At 10:06 am LPA observed Lysol and Clorox wipes located on rack above toilet in bathroom accessible to residents. During today’s visit, LPA observed the following: -at 11:15 am LPA observed that the water measured at 124.3. -at 11:17 am LPA observed that the locks on medication cabinet where on the cabinet, but not engaged. LPA observed that the bottle of Lysol was removed from cabinet under the bathroom sink. LPA also observed that the bottle of Lysol and Clorox wipes were removed from the rack above the toilet in the bathroom. A Plan of Correction letter is being issued. As these citations have not been cleared, civil penalties will be issued for failure to correct. An exit interview was conducted and a copy of this report, civil penalties and appeal rights were provided to caregiver Chris Gaytos.the state’s words, verbatim · CDSS document, Jul 27, 2023

Type of visit: Case Management - Other

On 7/21/2023 Licensing Program Analyst (LPA) Felisa Shirley conducted a Case Management visit to follow up on the Annual processed on prior visits. LPA was greeted by Chris Gaytos, Staff. LPA spoke with Chris and explained the purpose of the visit was to gather information to complete Annuals processed on 3/28/23 and 5/19/23. The census for today is 4. The following documents were requested and received during the visit: · Copy of Liability Insurance · Updated LIC 500 The following deficiencies were observed during the visit: -At 09:55 am LPA took hot water temperate in facility kitchen and noted that it was 120.8 F. -At 09:57 am LPA observed that cabinet in kitchen which held medication was not locked. -At 10:03 am LPA observed that bed in first bedroom did not have proper layers. -At 10:05 am LPA observed that R1 had postural supports with no prescription -At 10:06 am LPA observed a bottle of Lysol under bathroom sink, cabinet did not have a lock -At 10:06 am LPA observed Lysol and Clorox wipes located on rack above toilet in bathroom accessible to residents. An exit interview was conducted and a copy of this report and appeal rights were provided to caregiver Chris Gaytos.the state’s words, verbatim · CDSS document, Jul 21, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jul 22, 2023

Maintenance and Operation Faucets used by the staff in the kitchen shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperture of hot water used to attain a temperature of not less than 105 degrees F and not more than 120 degree F. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. LPA found water temperature in kitchen to be 120.8, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2023

Plan of correction: Licensee will monitor water over next 24 hours and submit proof that water is between 105 F and 120 F bia fax to CCLD.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a)(1) · Plan of correction due date: Jul 22, 2023

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which coluld pose a danger if readily available to clients shall be stored where inaccessible to clients. (1)Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement was not met as evidenced by: Based on observation the licensee did not comply with the section cited above by having toxins accessible to clients which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2023

Plan of correction: Licensee will put a lock on cabinet door located under the bathroom sink and put all toxins in locked cabinet.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jul 22, 2023

Centrally stored medicines shall be kept in a safe and locked place. This requirement is not met as evidenced by: Based on observation, the licensee did not ensure safety by not locking up medications making them inaccessible to residents which could pose as an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2023

Plan of correction: Licensee shall lock at medications away and make inaccessible to residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(3)(c) · Plan of correction due date: Aug 4, 2023

(3)Equipment and supplies necessary for personal care and maintenance of a adequate hygience practice shall be readily available to each resident. (c)clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads This requirement is not met as evidenced by: Based on observation, the licensee did not ensure that residents were provided proper linens for bedding, which could pose as an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 21, 2023

Plan of correction: Licensee shall provide proper linens for residents beds.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87608(a)(3) · Plan of correction due date: Aug 4, 2023

(a) Based on the individual's preadmission appraisal, Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Based on observation and file review, the licensee did not ensure safety by having postural supports on residents bed, which could pose as an immediate health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Jul 21, 2023

Plan of correction: Licensee shall remove hospice rails and provide a copy once removed to CCLD via fax.

Type of visit: Case Management - Annual Continuation

On 05/19/23 Licensing Program Analyst (LPA) Felisa Shirley returned to facility to continue unannounced annual required visit with using the new CARE Inspection Tool. LPA met with caregiver Chris Gaytos and explained the purpose of today’s visit. The facility is licensed to operate for four (4) elderly residents ages 60 and above. The facility is approved for four (4) non ambulatory of which one (1) can be bedridden and two (2) can be under hospice care. LPA Shirley continued the inspection tour. The facility is a single-story structure located in a residential neighborhood. The facility consists of the following: three (3) resident's rooms, a staff room, three (3) bathrooms of which one (1) is designated for staff and visitors only, a living room area, a dining area, kitchen and a converted detached room which is used for staff. The washer and dryer are located next to the kitchen. LPA retest the water temperatures. Water delivered at 131.5 F. Advisory Notes – Four (4) Technical Assistance were issued, please see LIC9102-AN. Two (2) deficiencies were cited during this inspection visit. See the Case Management 809 D pages. An exit interview was conducted and a copy of this report was provided to caregiver Chris Gaytos.the state’s words, verbatim · CDSS document, May 19, 2023

Type of visit: Required - 1 Year

On 03/28/2023, Licensing Program Analyst (LPA) Felisa Shirley and Licensing Program Manager (LPM) Stephanie Cifuentes conducted an unannounced annual required visit with using the new CARE Inspection Tool. LPA met with caregiver Chris Gaytos and explained the purpose of today’s visit. The facility is licensed to operate for four (4) elderly residents ages 60 and above. The facility is approved for four (4) non ambulatory of which one (1) can be bedridden and two (2) can be under hospice care. The facility is a single-story structure located in a residential neighborhood. The facility consists of the following: three (3) resident's rooms, a staff room, three (3) bathrooms of which one (1) is designated for staff and visitors only, a living room area, a dining area, kitchen and a converted detached room which is used for staff. The washer and dryer are located next to the kitchen. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are three (3) fire extinguishers fully charged in the kitchen and the dining room. Resident bathrooms were checked. Toilets and water faucets were operable, grab bars were secure, shower was free of mold/mildew. The following deficiencies were observed during the visit: -At 1:23pm LPA took hot water temperate in facility bathroom and noted that it was 150.3F -At 1:20pm LPA observed that drawers in kitchen which held knives and toxins were not locked. -At 1:20pm LPA observed that hall closet was unlocked and had a pair of scissors on one of the shelves. -At 1:24pm LPA observed that facility bathroom did not have non-slip mat. -At 1:20PM LPA observed that oven in facility kitchen was not operational. Due to time constraints, annual inspection could not be completed at this time. LPA will return at a later date for an annual continuation. An exit interview was conducted and a copy of this report and appeal rights were provided to caregiver Chris Gaytos.the state’s words, verbatim · CDSS document, Mar 28, 2023

Type of visit: Required - 1 Year

On 03/15/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with caregiver Chris Gaytos and explained the purpose of today’s visit. The facility is licensed to operate for four (4) elderly residents ages 60 and above. The facility is approved for four (4) non ambulatory of which one (1) can be bedridden and two (2) can be under hospice care. The facility is a single-story structure located in a residential neighborhood. The facility consists of the following: three (3) resident's rooms, a staff room, three (3) bathrooms of which one (1) is designated for staff and visitors only, a living room area, a dining area, kitchen and a converted detached room which is used for staff. The washer and dryer is located next to the kitchen. LPA and caregiver Chris Gaytos toured the physical plant. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition,adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are two (2) fire extinguishers fully charged in the kitchen and the dining room. First aid kit was located and stored in near the Medications. Smoke detectors and carbon monoxide were operable. Evaluation Report Continues on LIC 809-C. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed four (4) residents and two (2) staff present during the tour. Advisory Notes – Four (4) Technical Assistance were issued, please see LIC9102-AN. Five (5) deficiencies were cited during this inspection visit. See the Case Management 809 D pages. An exit interview was conducted and a copy of this report was provided to caregiver Chris Gaytos.the state’s words, verbatim · CDSS document, Mar 15, 2022

The state marks this report as 6 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Don Senaha conducted a Case Management as part of the annual review required to cite the facility for deficiencies. Annual review was conducted on 3/15/22 and deficiencies were cited on 3/15/22. There were five (5) deficiencies cited during the visit. LPA discussed on the phone with Administrator Mark Loo all deficiencies and caregiver Chris Gaytos was ok to sign per Mark.the state’s words, verbatim · CDSS document, Mar 15, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Mar 17, 2022

87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained to automatically regulat the temperature of hot water used by residents to attain a temperature of not less than 105 degrees F and not more than 120 degrees F. This requirement is not met as evidenced by: Based on observation by LPA, the water tempeerature in the kitchen sink measured 130.5 F at 10:06am and 130.8 F at 10:18am in the shared bedroom bathroom which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 15, 2022

Plan of correction: Per Administrator will adjust water and send pictures of the water temperature via email or text to LPA by 3/17/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Mar 17, 2022

87309(a) Storage Space. Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation by LPA, there was bleach and laundry detergent on an open shelf next to the clients shared room which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 15, 2022

Plan of correction: Caregiver immediately moved the disinfectants and cleaning solutions to a locked cabinet.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 29, 2022

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, LPA observed a resident dresser on R4 room without handles to open the drawer at the facility which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 15, 2022

Plan of correction: Per Administrator will fix or replace the dresser by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Mar 29, 2022

87506(a) Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and licensing agency staff. This requirement is not met as evidenced by: LPA observed the resident record of the Medication Administration Records (MAR) were not up to date and maintained correctly which poses a potential health ad safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 15, 2022

Plan of correction: Administrator will do an in-service training and send me signed logs of records being maintained including the MAR.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(2) · Plan of correction due date: Mar 17, 2022

Personal Rights To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by: Based on observation by LPA, resident R1 was in the converted garage room shared with a staff which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 15, 2022

Plan of correction: Per Administrator will move the resident R1 back to her room in the facility by 3/17/22.

Allegation investigated: Severe neglect resulting in resident developing a pressure injury. Facility failed to address resident's change in medical condition .

Licensing Program Analyst (LPA) Ulysses Coronel made an unannounced visit to the facility, LPA met with caregiver Crisostomo Gaytos and spoke to Administrators Sherryl Rafols and Mark Loo via telephone. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The insvestigation consisted of the following: Licensing Program Analyst (LPA Jennifer Jones) conducted the Initial 10-Day visit on 11/14/19. During the visit, LPA Jones met with Staff #1 (S1: Crisostono Gaytos) and Staff #2 (S2: Marilyn Nery), toured the facility, reviewed Residents (1-5) files, and obtained copies of Resident #1's files (Physician’s Report, Admission Agreement, Emergency Contact Info, and Home Health Agency notes) including facility staff training records. A separate investigation was conducted by the Department of Social Services Investigator (Laura Garcia) which included reviewing medical records and home health agency notes (dated 08/29/19 – 11/06/19); interviews with facility staff, residents’ relatives, home health staff, and medical staff. Substantiated Regarding Allegation #1: this investigation revealed that upon admission to the facility on 08/25/19, the physician’s report (dated 08/01/19) documented that Resident #1 (referred to as R1) had a history of skin condition/breakdown. Medical records (dated 08/26/19) noted a physical examination was performed on Resident #1 for pressure injuries present during hospital admission: right toe – Stage 2; Right heel – Stage 3 without surrounding erythema or purulence; severe Sepsis with acute organ dysfunction, non-traumatic acute kidney injury, BPH with urinary retention, Dementia, severe protein calorie malnutrition, venous statis edema with ulcer. Home health agency records (dated 08/26/19) documented that Resident #1 was referred to ComCare Home Health (an affiliate of Kaiser Permanente Medical Group) and was first seen by one of the on-site home health agency nurses on 08/29/19 for start of care. Home Health RN noted multiple wound locations: Unstageable pressure injuries on the left and right buttock/ open-skin injury on right toe, and open Stage 2 pressure injury on right heel. All wounds were reported to physician and coordinated to facility staff. ComCare Home Health Skilled Nurse (Florence Atena) instructed PCG’s in pressure management and prevention; of which, facility staff verbalized understanding. Medical records (dated 09/28/19) revealed that Resident #1 was hospitalized due to severe sepsis and was discharged back to the facility on 10/03/19. Resident #1 had wounds on: left heel – unstageable pressure injury; right heel – open Stage 2 pressure injury, measuring 3x3x0cm; right great toe – open skin injury, measuring 1x0.5x0cm; left buttock – unstageable . ComCare Home Health received the order (dated 10/04/19) to resume home health care to Resident #1. Staff #1 told ComCare Home Health Skilled Nurse, Florence Atena (on 10/11/19) that he had performed wound care on Resident #1’s sacrococcyx and did not allow Skilled Nurse Atena to turn Resident #1 (again) to check the wound. Skilled Nurse Atena documented and reported Resident #1’s health and behavioral condition. Based on Skilled Nurse Atena’s observations, it was believed that Resident #1 required a higher level of care. Skilled Nurse Atena continued daily wound care visits for Resident #1 and foley catheter change on 10/16/19. On 10/23/19, upon re-cert visit, Home Health RN, noted an unstageable pressure ulcer on Resident #1’s left hip and reported to medical doctor about the new wounds and recommended wound care treatment. On 11/06/19, Resident #1 was hospitalized due to a septic shock, dehydration, and pressure injuries. Resident #1 expired on 12/04/19. Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation NEGLECT/LACK OF SUPERVISION: Severe neglect resulting in resident developing a pressure injury is found to be SUBSTANTIATED. Regarding Allegation #2: this investigation revealed that on 10/23/19, it was determined that Resident (#1) (referred to as R1) was diagnosed with the following pressure injuries: Wound 1 – right heel (measured 6.7 x 6.5 cm); Wound 2 – left heel (measured 3.5 x 3.2 cm); Wound 3 – left hip (measured 10.4 x 6.7 cm); Wound 4 – right hallux, no odor, no drainage, wound bed appearance necrotic; Wound 5 – bilateral buttocks with moderate serosanguineous drainage, yellow wound bed appearance. ComCare Home Health instructions to facility staff were to keep these areas dry and clean as well as keeping pressure off by elevating and rotating Resident #1 regularly. A review of Resident #1’s “Needs and Services Plan” (dated 08/25/19) did not document information about potential pressure injuries or change in condition prior to the Resident #1’s hospitalization on 09/28/19. Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation NEGLECT/LACK OF SUPERVISION: Facility failed to address resident's change in medical condition is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency observed and citation issued (ref. LIC 9099D) – civil penalty will be assessed. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to Administrators Sherryl Rafols and Mark Loo.the state’s words, verbatim · CDSS document, Dec 16, 2021 · control 11-AS-20191113101336

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Dec 17, 2021

Prohibited Health Conditions: Persons who require health services or have a health condition including; but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure sores (dermal ulcers). This requirement is not met as evidenced by: Upon admission R1 Physician’s Report (8/1/19) documented that R1 had a history of skin breakdown, Stage 3 pressure injury on the right heel/arterial ulcer. On 11/6/19, R1 had 3 unstageable pressure injuries. Staff was aware of R1’s wound condition and retained R1 with a prohibited health condition. R1 expired on 12/04/19.the state’s words, verbatim · CDSS document, Dec 16, 2021

Plan of correction: The administrator shall read Title 22, Section 87615(a)(1) "Prohibited Health Conditions" and send a written statement to CCLD by the POC date that she will ensure to stay in constant communication with the medical professional; and if the resident's medical condition elevates (meaning they require a higher level of care), Administrator will ensure the resident is relocated to a skilled-nursing facility or hospital; and, the relocation will take place immediately. This POC is due to CCLD/El Segundo ASC Office on 12/17/2021.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 17, 2021

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as ... physical health condition are observed , the licensee shall ensure that such changes are documented and brought to the attention of the resident’s physician and the resident’s responsible party, if any. This requirement is not met as evidenced by: Facility staff admitted to having knowledge of Resident #1’s change of medical condition.the state’s words, verbatim · CDSS document, Dec 16, 2021

Plan of correction: The administrator shall read Title 22, Section 87466 “Observation of the Resident” and send a written statement to CCLD by the POC date that Administrator will observe any change of condition by a resident and conduct an assessment of the resident and inform the resident’s physician and resident’s responsible person of an outcome. The plan is due to CCLD/El Segundo ASC Office by POC date of 12/17/2021.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Ulysses Coronel made an unannounced visit to the facility and was greeted by caregiver Crisostomo Gaytos and spoke to Administrators Sherryl Rafols and Mark Loo via telephone. The purpose of this visit is to deliver a generated Case Management – Deficiencies, evaluation report in conjunction with Complaint Control #11-AS-20191113101336 due to the following observations: This investigation revealed that Resident #1 was restrained to the bedrails utilizing pieces of cloth sheets and shirts. The cloth restraints were placed around the resident’s wrists – while the resident was wearing gloves. Staff #1 admitted the purpose of the restraints were to prevent Resident #1 from removing the Foley catheter and scratching its wounds; as the resident would get agitated. Staff #1 expressed the necessity to occasionally restrain Resident #1 in different positions in order to prevent the resident from placing pressure on its wounds. On several occasions, ComCare Home Health Nurse observed Resident #1 tied to the bed rails in this same manner and would instruct Staff #1 to immediately remove the restraints. It seemed to be a reoccurring event requiring the HHA Nurse to repeatedly order Staff #1 to remove these restraints from Resident #1. Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation PERSONAL RIGHTS: Resident was restrained by the hands to the bedrails is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency was observed and a citation issued (ref. LIC 9099D). An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to Administrator (FULL NAME).the state’s words, verbatim · CDSS document, Dec 16, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 24, 2021

87468.1(a)(3) Personal Rights of Residents in All Facilities: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature; such as, withholding residents money or interfering with daily-living functions; such as, eating, sleeping, or elimination. This requirement is not met as evidenced by: Staff #1 admitted the purpose of the restraints and expressed the necessity to occasionally restrain Resident #1 in different positions. Which poses a potential Health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 16, 2021

Plan of correction: The administrator shall read Title 22, Section 87468.1(a)(3) “Personal Rights of Residents in All Facilities” and send a written statement to CCLD by the POC date that Administrator will ensure that a resident in the facility will be free from punishment and abuse or other actions of a punitive nature. The plan is due to CCLD/El Segundo ASC Office by POC date of 12/24/2021.