Summerfield of Stockton

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson arrived at facility to conduct a Case Management visit to address the Departments investigation into multiple incidents that occurred on different days involving aggressive acts by residents on other residents. The facility was given a citation on 4/7/2023 for "Care of Persons with Dementia" and "Reappraisals." The facility has appealed the citations given on 4/7/2023. The appeal states that the facility did not decrease their staffing levels and claims the Department’s assertion they had is untrue. The appeal states that, "Even if the facility had reduced the number of staff that regulation only states that a facility must ensure there is an adequate number of direct care staff to meet resident needs." The appeal further stated that The Department failed to establish that decreased staffing levels resulted in a resident’s death. The appeal was granted by the Department and the citations will be removed. During the review of this matter the Department discovered that the facility employed an individual that was excluded for life on or about June 5, 2018 and that individual has been working since October 21, 2022 to last day worked August 18, 2023. This was confirmed by unemployment papers provided to Oasis P.E.O Claims by the facility for S1. Citation given on this day for Criminal Record Clearance on the attached 809 D page.the state’s words, verbatim · CDSS document, Oct 5, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1)(2)(3) · Plan of correction due date: Oct 6, 2023

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by: records reviewed The facility employed an individual that was excluded for life on or about June 5, 2018 and that individual has been working since October 21, 2022 to last day worked August 18, 2023.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: The staff is no longer working at the facility. A request has been made to have S1 reinstated. Civil penalty assessed

Allegation investigated: Staff not providing adequate supervision to residents in care. Staff did not provide medical attention in a timely manner. Resident was left in soiled diaper for an extended amount of time.

Allegation: Staff not providing adequate supervision to residents in care. Based on interviews with the Staff present that day and the Administrator, the department discovered that R1 was not out of the building, R1 was sleeping in another residents room. R1 left the activities group and went into another residents room, laid down resting when staff located her. According to the records reviewed and statements given, R1 was never lost, however she was not in her room and her assigned companion was having trouble locating R1 until a staff member overheard the concern and pointed out the location of R1. The time frame was roughly 15 minutes from the time the question about the location of R1 and the time R1 was secured with her companion. Allegation: Staff did not provide medical attention in a timely manner. Continued Unsubstantiated R2 had just been taken back from the living room to her bedroom, by her son, who was visiting, and one of Summerfield's caregivers, at around 10:10 am. R2 was tired and asked to take a nap. The Summerfield caregiver and son laid her on her side in bed. Hansel came back to check on R2 at approximately 10:15 and the Home Health nurse arrived at 10:30 and that is when she tried to wake up R2 and said she is unresponsive. At 10:30am Home Health RN had just come to check up on R2 because she had a fall on 07/31/2023 and Home Health was ordered for follow up care. The nurse told Hansel who was in the hallway that R2 needed to be checked and she was unresponsive. 911 was immediately called and the medics arrived. When the Medics left her R2 was awake and responsive to the Paramedics. She was taken to St. Joseph's Hospital. Home Health RN and Hansel LVN from Summerfield attended to R2 immediately when they noticed a change of condition and they called 911. Allegation: Resident was left in soiled diaper for an extended amount of time. Based on interviews conducted, R1 spends every morning in the Activity Room doing her exercises. Dixen, the Activity Director, said she had left as soon as exercise was done. She does get tired and wants to lay down. R1 went to the first open room door she could find and laid down on one of the beds with the door still open. She had gone to Activities at 9:00am and then laid down around 9:50 right after she left Activities, she was woken up at 10:30. As a result of this investigation, this Department finds the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administratorthe state’s words, verbatim · CDSS document, Aug 17, 2023 · control 27-AS-20230801114146

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Albert Johnson arrived at facility to conduct a Case Management visit due to multiple incidents involving aggressive acts resulting in a death, aggressive acts resulting in a resident hitting another with a fire extinguisher. Based on records reviewed and incidents which resulted in a death and bodily injury, the department is requesting that the facility increase the staffing to address the lack of supervision which has resulted in these unfortunate incidents including a death. LPA was able to determine that the facility has reduced the number of staff on the AM shift from eight staff to seven staff and the same for the PM shift from eight to seven. The NOC shift was staffed at four and now staffed at three. As a result of this reduction in staffing the facility has compromised the safety of the residents in care. On 2/13/2023 R1 was assaulted by R2 resulting in R1 going to the ER for evaluation. The discharge summary diagnosed "Assault and back Pain. R1 has since moved out of the facility. Continued The service plan for R2 has not been updated to address the assaultive behavior. On 3/4/2023 R3 was assaulted by R4 resulting in R3 going to the ER for evaluation. R3 was placed on comfort care, due to a brain bleed and stroke. R3 passed away in the hospital. The service plan for R4 has not been updated to address the assaultive behavior. Both incidents were reported to the Stockton Police department and a Report of Suspected Dependant Adult /Elder Abuse report was submitted as required. Per California Code of Regulations, Title 22, the following deficiencies and immediate civil penalty have been issued. The circumstances of these incidents are being evaluated for additional civil penalties. Exit interview.the state’s words, verbatim · CDSS document, Apr 7, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(1-2)(c)(4) · Plan of correction due date: Apr 8, 2023

(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4)There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by incidents of aggression resulting in death and injury and lack of updated service plans for R2 and R4. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2023

Plan of correction: Licensee will schedule an in-service training to include the complete regulation 87705, additionally the facility will added additional staff to ensure resident safety. Licensee to send copy of in-service training to CCL after it's completed to clear deficiency. Civil penalties assessed

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(c) · Plan of correction due date: Apr 21, 2023

The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met as evidenced by review of current records for R1 and R4. also missing signatures for R5's assessment. This poses a potential safety risk to residents in carethe state’s words, verbatim · CDSS document, Apr 7, 2023

Plan of correction: The facility wiil follow the guidelines for "Resident Participation in Decision Making" and have signed service plans for all residents in care. The facility will complete this by POC date 4/21/2023. The Adminstrator will provide the department with the signatures after meeting with the families.

Type of visit: Required - 1 Year

Licensing Program Analyst Albert Johnson arrived unannounced to conduct an Annual inspection. LPA inspected the physical plant with including but not limited to the kitchen, bedrooms for residents, resident bathrooms, laundry area and general assembly area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 118.9 degrees Fahrenheit, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications and toxins are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 10 resident and 5 staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. During the resident's file review, LPA observed that the service plans are not signed by the responsible parties or the residents for 10 of 10 files reviewed. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed and cited during this visit. Exit interview held and a copy of report given with appeal rights at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 12, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(c) · Plan of correction due date: Jan 26, 2023

The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met as evidenced by missing signatures on all (10 of 10) service plans for R1 thru R10 reviewed. This poses a potential safety risk to residents in carethe state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: The facility wiil follow the guidelines for "Resident Participation in Decision Making" and have signed service plans for all residents in care. The facility will complete this by POC date 1/26/2023. The Adminstrator will provide the department with the 10 signatures after meeting with the families to the department.

Type of visit: POC

Licensing Program Analyst (LPA) Johnson arrived at facility and met with staff to conduct a POC visit from an annual inspection and a plan of correction visit. POCs corrected Deficiencies cleared. POC letters printed. Exit interview.the state’s words, verbatim · CDSS document, Apr 14, 2022

Type of visit: POC

LPA Albert Johnson arrived unannounced for a case management visit. To follow-up on clarification with the Licensee if there has been any progress in the change of ownership since the last request on 11/24/2021 and to confirm who has current control of property, when the residents were notified of any changes and if there was a change to the management company. During the inspection on 11/23/2021 LPA Johnson requested to the department the required information outlined in this regulation 87211(a)(h). (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (h) Any change in the chief corporate officer of an organization, corporation or association shall be reported to the licensing agency in writing within fifteen (15) working days following such change. Such notification shall include the name, address, and the fingerprint card of the new chief executive officer, as required by Section 87355, Criminal Record Clearance. The information was to be submitted to the department by 12/03/2021. LPA Johnson has not received this information as of this date 3/17/2022. The repeat citation will be included on the attached 809D page. Continued. The facility was to submit documents to the Department on February 27, 2022 and to this date the facility/licensee et.al. have not provided the requested information. As of today March 17, 2022 the following items are still outstanding: Section A Documents: A4. Administrative Organization (LIC 309) · Resubmit LIC309 – box 8, include percentages of ownership. A7. Monthly Operating Budget (LIC 401) · Resubmit LIC401 – line 7, revise Food Costs, should be at minimum $200 per resident. Resubmit LIC401 – line 27, include monthly rent. A9. Financial Information Release and Verification ·Submit – Northstar Senior Living, Inc bank statement, from within the past 60-days, to demonstrate one month’s operating costs (line 37 of LIC401). A10. Personnel Report (LIC 500) Resubmit LIC500 – specify days of shifts. A13. Criminal Record Statement (LIC 508) Submit LIC508 – for Leslie. Section B Supportive Documents: B1. Partnership Agreement/Articles of Incorporation/Articles of Organization ·Submit – Articles of Incorporation (from Secretary of State) for Northstar Senior Living, Inc. Other: RCFE Disclosure Worksheet (LIC606) – submit. ·COVID 19 Mitigation Plan (LIC 808) – submit (Licensee may have one on file; can submit).Driver’s License – submit, for Leslie, to complete facility association. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed and cited during this visit. Exit interview held and a copy of report given and appeal rights at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 17, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(h) · Plan of correction due date: Mar 18, 2022

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (h) Any change in the chief corporate officer of an organization, corporation or association shall be reported to the licensing agency in writing within fifteen (15) working days following such change. Such notification shall include the name, address, and the fingerprint card of the new chief executive officer, as required by Section 87355, Criminal Record Clearance. This requirements was not met based on lack of records to review and interviews conducted. This poses an immediate health and safety concern for residents in care.the state’s words, verbatim · CDSS document, Mar 17, 2022

Plan of correction: The licensee will submit to the department the required information outlined in this regulation(87211(a)(h). The information will be submitted to the department by 03/18/2022.

Type of visit: Required - 1 Year

Licensing Program Analyst Albert Johnson arrived unannounced to conduct an Annual inspection. LPA met with the Leslie Anderson Administrator. LPA inspected the physical plant with including but not limited to the kitchen, bedrooms for residents, resident bathrooms, laundry area and general assembly area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112.9 degrees Fahrenheit, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications and toxins are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA that the facility is not following the Doctor's order for PRN medication administration. R1 and R2 were given PRN medication without notifying the primary care Physician, The PRN letter in both residents file request that the Primary care physician (PCP) be notified prior to giving the PRN medication. The facility did not notify the PCP for R1 or R2 prior to giving medication on multiple occasions. This information was reviewed in the residents medication administration record. LPA reviewed 10 resident and 5 staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed and cited during this visit. Exit interview held and a copy of report given with appeal rights at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 17, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(1)(2) · Plan of correction due date: Mar 18, 2022

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication.(2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by lack of records for R1 and R2, as well as an interview with Med-Tech on duty. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 17, 2022

Plan of correction: The facility will develop a plan to meet the regulatory requirement outlined in this regulation and submit the plan to the department by POC date 3/18/2022.

Type of visit: Office

An Office meeting conference was conducted today via teleconference by the Sacramento South Regional Office. The purpose of this meeting was to discuss the facility's change of name and new management operations. Present in the meeting were Regional Managers (RM) Krystall Moore ( Sacramento South), RM Leslie Mendiveles ( San Bernardino) and RM Brenda White (Fresno), Licensing Program Managers, Stephen Richardson ( Sacramento South) Czarrina Camilon Lee ( Sacramento South) and John Rante ( San Diego), Licensing Program Analyst Albert Johnson ( Sacramento South), NorthStar representatives Steve Kregel, Evelyn Mendez- Choy, Brook Lowther and Scott Putnam, Administrator Leslie Anderson, and SNH representatives Jennifer Francis, Jacquelyn Anderson, Kristin Gowdy and Centralized Application Bureau representatives Hao Nguyen, Tracy Thompson and Jude De la Concepcion. The purpose of the meeting was to discuss Northstar operational/management of the facilities owned by SNH Statewide. Continued Issues discussed during the meeting were: · Administrative Organization · Change of Ownership/management company (CHOM) · New Application The Licensee will do the following: · Licensee submitted an abbreviated application to add the management company today 11/29/21. · Northstar will not assume operational control of the facilities until the applications are approved. · SNH understands that they will remain responsible for facility until the change of management is approved. · Licensee will consult with Northstar until a new Management company is approved and SNH will hire/appoint Executive Directors at all facilities until the CHOM is approved. LPA provided a copy of this report with appeal rights.the state’s words, verbatim · CDSS document, Nov 29, 2021

Type of visit: Case Management - Other

LPA Albert Johnson arrived unannounced for a case management visit. The reason for the visit was to clarify with the Licensee if there have been any changes in ownership since the license was opened 3/6/2020 and to confirm who has current control of property, when the residents were notified of any changes and if there was a change to the management company. Business Office Manager confirmed that the facilities' management responsibilities were taken over on 10/1/2021 by Northstar Senior Living and that the control of property is with SNH CAL TENANT LLC. LPA was able to make contact with Regional Vice President of Operation Evelyn Mendez -Choy and Brook Lothwer Operation and Marketing Specialist via telephone. LPA requested a copy of agreement as the management company for this facility, Contact for (CDSS) California Department of Social Services Central Application Bureau, Resident notification letter regarding the change in management companies. The facility has changed it's name to Summerfield of Stockton Memory Care. This was confirmed by LPA's observation and review of new resident move-in checklist and facilities' brochure with a "New RCFE license Pending number 397001229" and the sign on the front of the building. Continued Also discussed was who the current LIC 308 (DESIGNATION OF FACILITY RESPONSIBILITY) is for the facility when the assigned Administrator of record is not at the facility. Based on this visit the Sacramento Adult and Senior Care Regional Office is requesting a meeting with you to discuss the operation of this licensed facilities. Your attendance at this meeting is mandatory. A tele-conference meeting has been scheduled for: Monday, November 29, 2021 at 1:30 PM. Contact information will be provided on Monday 11/29/2021. There are deficiencies being issued today. Exit interview conducted and a copy of this report provided to Business Office Manager on-site along with appeal rights. Additionally this report was sent via email to: Regional Vice President of Operation Evelyn Mendez -Choy and Operation and Marketing Specialist Brook Lothwer.the state’s words, verbatim · CDSS document, Nov 23, 2021

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.15(a)(3)(f) · Plan of correction due date: Nov 24, 2021

(a) Any person seeking a license for a residential care facility for the elderly under this chapter shall file with the department, pursuant to regulations, an application on forms furnished by the department, that shall include, but not be limited to, all of the following:(3) If applicable, the following information: (F) The name and address of any management company serving the facility and the same information required of applicants in subparagraphs (C) and (D) for the management company. This requirement is not met based on observation and records reviewed. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Nov 23, 2021

Plan of correction: The facility will provide the department with a copy of the application that was completed per Operations Marketing Specilist and a copy of the notification letter sent to the Residents or their Responsible Parties and the Contact for the Central Application Bureau that has been working with the facility on this update to the license by 11/24/2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(a)(h) · Plan of correction due date: Dec 3, 2021

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (h) Any change in the chief corporate officer of an organization, corporation or association shall be reported to the licensing agency in writing within fifteen (15) working days following such change. Such notification shall include the name, address, and the fingerprint card of the new chief executive officer, as required by Section 87355, Criminal Record Clearance. This requirements was not met based on lack of records to review and interviews conducted.the state’s words, verbatim · CDSS document, Nov 23, 2021

Plan of correction: The licensee will submit to the department the required information outlined in this regulation. The information will be submitted to the department by 12/03/2021.

Type of visit: POC

LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citation issued during the annual inspection on June of 2021 Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date. Facility was provided POC cleared letter. Exit interview conducted.the state’s words, verbatim · CDSS document, Jul 29, 2021

Type of visit: Post Licensing

The Post licensing visit was completed. LPA reviewed staff and residents records the records were complete. No deficiencies for the post licensing visit.the state’s words, verbatim · CDSS document, Jun 14, 2021