The Leaning Pine

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 09/14/2023. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Administrator Elna Villaflor arrived shortly after to assist with visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for five (5) non-ambulatory residents and one (1) bedridden resident. LPA OBSERVATIONS: Tour began at 9:00 am and was led by Administrator Villaflor. The facility is a single-story building located in a residential neighborhood with four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, dining room, living room, den, front yard, backyard, and attached garage. Front Yard: Was clean and well maintained. No hazards were observed. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet to be inaccessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 105.9 degrees F. Kitchen appliances were observed to be clean and in working order. Dining Room/Living room/Den: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher in this area. LPA Ramirez observed three (3) out of six (6) residents in care watching television in den area. Linen Closet: Contained plenty linens, towels, and hygiene products. See 809-C for continuation. Resident Rooms 1 - 4: LPA Ramirez observed four (4) out of the four (4) resident bedrooms to contain the furnishings, lighting however, bedroom #1 mattress belonging to resident#1 (R1), was observed to not contain required linen. LPA Ramirez discussed with Administrator Villaflor as to the reason as to why R1’s mattress did not have required linen and LPA Ramirez will issue Technical Advisory. Due to the best interest of R1’s health and needs, facility staff will not place linen on mattress and provide physician order or updated health care plan. LPA Ramirez observed required auditory devices to sound when resident patio door is opened. Resident rooms appeared to be clean. Bathrooms: Signs promoting hand washing were observed. Water temperature in resident bathroom#1 was measured at 106.4 degrees F which is in the required 105 – 120 degrees F. Bathroom #2 was observed to be clean and water temperature was measured at 105.2 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilets and in walk-in showers, in all bathrooms. Centrally Stored Medications: LPA observed cabinet located in staff office to be locked and inaccessible to residents in care. Backyard: LPA observed plenty of seating and shade. No large bodies of water were observed. Emergency Drills: Proof of last documented fire drill was conducted 09/02/23. Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways. LPA Ramirez observed posted Emergency Disaster Plan. Staff Personnel Files: Staff files are maintained at facility. LPA Ramirez reviewed staff files for two (2) live in staff. LPA Ramirez observed Administrator’s certificate for Elna Villaflor (6017647740) with an expiration date of 06/05/2024. Resident Files: Six (6) resident files were reviewed. Admissions agreements and resident personal rights were observed in files. Liability Insurance & Infection Control Plan: LPA Ramires observed current liability insurance and approved infection control plan was already submitted to this department. No deficiencies are being cited. Exit interview was conducted with Administrator Villaflor and a copy of this report, LIC 9102 and appeals rights was provided.the state’s words, verbatim · CDSS document, Sep 14, 2023

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not issue a proper refund.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Staff Romulo Celebrados. The purpose of the visit was explained. Administrator, Elna Villaflor, arrived shortly thereafter to assist with the visit. LPA obtained a copy of the staff and resident roster, reviewed and obtained copies of Resident #1's (R1) file. Interviews were held with the Administrator and 2 Staff. The investigation revealed the following: Allegation - Facility staff did not issue a proper refund. Per the Administrator, Resident #1's (R1) responsible party was issued a refund in the amount of $1,250 for the 5 days that R1 was residing at the facility. LPA obtained a copy of the itemized charges with the amount refunded. Upon review of the statement, LPA observed that the days charged for care and supervision was for 2 weeks. Substantiated Per the Health and Safety Code section 1569.652, (a) A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit. R1 was admitted to the facility on 2/24/23 and passed away on 2/28/23. Therefore, it appears that the billing for 2 weeks was incorrect and the refund amount should have been greater than what was refunded. Based on record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Health & Safety Code, Chapter 3.2), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided. LPA reviewed the admission agreement and the responsible party initialed the consent to be photographed for R1. Based on information gathered, there is insufficient evidence to corroborate this 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 UNSUBSTANTIATED. An exit interview was conducted with the administrator. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, May 30, 2023 · control 28-AS-20230522100241

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(a) · Plan of correction due date: Jun 13, 2023

§1569.652 Termination of admission agreement upon death of resident;... (a) A residential care facility for the elderly shall not require advance notice...upon the death of a resident. No fees shall accrue... This requirement is not met as evidenced by: Based on record review and interview, Resident #1 was billed for 2 weeks for care and supervision provided which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2023

Plan of correction: The licensee shall redetermine the amount billed for R1 prior to decease and ensure the family was issued the correct amount. The POC is due by 6/13/23.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) conducted a case management visit to issue deficiencies observed during a complaint investigation on 5/30/23. LPA met with administrator, Elna Villaflor, to explained the purpose of this case management. During the complaint investigation for control #28-AS-20230522100241, LPA observed some deficiencies pertaining to the admission agreement. Per observation of Resident #1's (R1) records, the admission agreement was missing the basic rate fees and/or fees for any level of care, although it was signed by the responsible party. In addition, the refund amount was not issued within 15 days after the personal property was removed. R1 passed away on 2/28/23 and Resident #1's (R1) family was issued the refund on 4/26/23. Based on information gathered, the deficiencies are issued on the LIC809D. An exit interview was held and a copy of this report along with appeal rights was given to the administrator.the state’s words, verbatim · CDSS document, May 30, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(A)(1) · Plan of correction due date: Jun 13, 2023

87507 Admission Agreements (g) Admission agreements shall...(3) Payment provisions, including the following: (A) Rate for all basic services...1. A comprehensive description of any items and services provided under a single fee... This requirement is not met as evidenced by: Based on record review, Resident #1's admission agreement did not list the monthly rates and/or other services rates which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2023

Plan of correction: The licensee shall ensure the admission agreement is filled out in its entirety with the basic rates and any additional services provided. (continue below) The licensee shall review all the residents' admission agreements to ensure the rates are accurate and submit a statement indicating the records have been reviewed. The POC is due by 6/13/23.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.652(c) · Plan of correction due date: Jun 13, 2023

H&S 1569.652 (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual...within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on record review, Resident #1 passed away on 2/28/23 and the responsible party was issued a refund on 4/26/23 which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 30, 2023

Plan of correction: The licensee shall review the admission agreement and health and safety code on refund policies to ensure that refunds are issued proper and timely. The statement acknowledging these regulations have been read is due to LPA by 6/13/23.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA was allowed entry by Staff, Zenaida Uy. Administrator, Elna Villaflor, arrived at 3:10 pm to assist with the inspection. The facility is licensed to serve five (5) non-ambulatory and one (1) bedridden residents, ages 60 and over. The bedridden fire clearance is approved for room #1 only. The facility has an approved mitigation plan. LPA toured the facility and observed the following: * There are 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, staff rest area, and an attached garage. There are no pools or bodies of water and no items obstructing the passageways. * Coronavirus (COVID-19) signage are posted throughout the facility to promote hand washing hygiene, cough/sneeze etiquette, and symptom checks. * The facility continues to screen and take the temperature of all visitors. * Sufficient supplies of PPE are stored at the facility. * Food supplies for 2 day perishable and a week of non-perishable are also observed. * Knives, cleaning solutions, and disinfectants are stored and locked making them inaccessible to residents. * Smoke detectors are connected to the security alarm system. There is one carbon monoxide detector and is operable. * Medications are centrally stored and locked in the kitchen cabinet. LPA reviewed all 3 residents' medications and staff are administering them as prescribed. Per the administrator, they are continuing to follow the strictest COVID-19 guidance. They clean and disinfect daily and more often for high touch surfaces. There are no deficiencies issued today. An exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 14, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer was greeted by administrator Elna Villaflor and discussed the purpose of today's visit. This single-story home contains four (4) bedrooms, two (2) bathrooms, caregivers quarters, living room, kitchen, dining area, backyard, and attached garage. The following was observed/inspected: The facility had a universal entrance screening area including a thermometer, PPE, screening logs, and sign-in sheet. COVID-19 signage was placed in several areas of the facility. Facility maintained a 30-day supply of PPE. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. Cleaning solutions and sharps were locked and inaccessible. Water temperature was measured and were within the required 105-120 degrees F. Each room contained required furniture including bed, dresser, night stand, lamp and chair. Each bed did not contain all of the required linen including mattress cover, fitted sheet, flat sheet, blanket and comforter. Bathrooms contained hygiene supplies including liquid soap, paper towels, and toilet paper. Medications were locked, central stored, and given as prescribed. Facility maintained 30-day supply. Staff did not wear face masks consistently throughout the shift and group activities were not spaced to encourage physical distancing. Smoke detectors/carbon monoxide detectors were present and operable. A fire extinguisher was observed to be fully charged and last serviced April 2021. Client files were inspected and emergency contact information and physician's reports were up-to-date. All staff files were inspected and contained required health screenings, criminal record clearances, and training certificates. Administrator certificate expires 6/2022. The outdoor passageways were obstructed with large items needing to be discarded. Pursuant to Title 22, deficiencies were cited on attached 809D. Technical advisories issued on separate LIC9102. An exit interview was conducted and a copy of this report were provided to the administrator.the state’s words, verbatim · CDSS document, Sep 24, 2021

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff does not safeguard residents' belongings. Facility staff open residents' mail.

***This is an amended report and supercedes report dated 8/11/21. Additional details were added, but the findings were not changed.*** Licensing Program Analyst (LPA) Nicole Spencer conducted an initial complaint investigation for the allegations listed above. LPA Spencer was met with staff#1 and was later met by administrator Elna Villaflor and discussed the purpose of today's visit. During the investigation, LPA Spencer took a tour of the physical plant and interviewed the administrator, staff #1-2 (S1-S2), residents #1-6 (R1-R6), and family members of a resident (F1-F2). R5 was non-verbal so the interview was discontinued, and F1 was unable to be reached. LPA Spencer obtained a copy of the staff roster, resident roster, admissions agreement and all resident files were reviewed. *Continued on LIC9099C* Unsubstantiated ***This is an amended report and supercedes report dated 8/11/21. Additional details were added, but the findings were not changed.*** The investigation consisted of the following: Regarding the allegation that facility staff does not safeguard residents' belongings, LPA Spencer reviewed the admissions agreement showing the facility's theft and loss policy includes inventory of residents personal property and valuables. LPA reviewed residents' files and observed that all residents had a completed personal property and valuables inventory list. Interviewed staff stated that if residents report missing items, the staff will look for the items, inform the responsible party, and replace the item if not found. Staff stated that any missing items are usually found in the resident's room. Three (3) out of five (5) residents stated that they have not had missing items, while two (2) out of five (5) stated they were missing items such as clothing and important papers. However, the resident reporting missing clothing stated that it was stolen by a staff member whose name was not listed on the staff roster, and the resident who stated they were missing important papers stated in a follow-up interview that it was later found in the resident's room. Regarding the allegation that staff open residents' mail, all staff interviewed stated that residents' mail is given to the residents' responsible party unless the resident is self responsible, independent and gets their own mail. All staff denied the allegation that staff open the residents' mail. The administrator stated that R6's mail was mistakenly forwarded to the administrator's P.O. Box and was partially opened and crumpled but gave it to the resident and explained what happened. The administrator stated that the mail was never opened by facility staff and it was likely damaged at the post office during the sorting of the mail. Four (4) out of five (5) residents stated that their family gets their mail and were unaware of staff opening residents' mail, while one (1) out of five (5) stated that two letters were pre-opened when the resident received it. Based upon interviews conducted and records reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated. An exit interview was conducted with Administrator Elna Villaflor and a hard copy of the report was provided. Three (3) out of five (5) residents interviewed stated that residents are not allowed to go outside of the facility at this time, one (1) of out five (5) stated that they are allowed to go in the backyard and have outings with family members once in a while, and one (1) stated that they were unsure. F2 stated that family members were previously taking R6 on outings and the facility was allowing R6 to go out independently, but recently the family has refused to provide transportation due to family disputes. In a follow-up interview with the administrator, the administrator clarified that they were previously allowing R6 to go out on outings using Dail-a-ride or arranging transportation through family, however, due to family disputes, the administrator did not allow the resident to leave based on the family's request. A review of R6's records shows that the resident is not conserved and can leave the facility unassisted. Per admissions agreement, the basic services include assistance with transportation. Based upon interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, Aug 11, 2021 · control 28-AS-20210803135523

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Aug 13, 2021

87468.1(a)(6) Personal Rights of Residents in all facilities. To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by... Based on interviews and records reviewed, the licensee did not ensure that residents were not restricted from leaving the facility. This poses a potential risk to the personal rights of persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: The administrator stated that she would provide in-service training regarding PINS about visitations and outings during COVID-19 and provide a copy of the relevant PINS to staff and residents. Administrator will provide a copy of training log to CCL by 8/13/21.