The Norma J's Home for the Elderly

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:30 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Loretta Tiede arrived shortly thereafter. The LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 regulations. BEDROOMS/BATHROOMS: Beginning at 11:00 a.m. the LPA inspected the bedroom and bathroom areas. Bedrooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are five designated resident rooms, one shared and four private resident rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. The resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured between at 116.9 and 117.6 degrees Fahrenheit. KITCHEN: The LPA inspected the kitchen/food service area, knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 73 degrees. Smoke detector(s) and carbon monoxide detector were tested at 11:25 a.m. and operational at the time of the visit. The two fire extinguishers were fully charged and last serviced Oct 17, 2023. The LPA observed required postings throughout the common spaces. Continued on LIC 9099-C OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate that is single latched. There is a gated pool in the backyard that was locked and inaccessible a the time of the visit. Exits are free of obstructions. The garage is attached, locked and inaccessible with an additional refrigerator with perishable food. Cleaning supplies and disinfectants are kept in locked in the garage. There is a laundry closet located in the hallway where the washer and dryer are held laundry supplies are kept locked in a locked cabinet. The facility keeps a sufficient amount of emergency food supplies and water in the garage. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. RECORDS: Residents’ records review began at 12:15 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Due to time constraints, the LPA will return at a later date to complete the inspection. The LPA obtained the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Liability Insurance - Disaster Planthe state’s words, verbatim · CDSS document, Oct 30, 2023

Allegation investigated: Staff inappropriately touched resident Staff made inappropriate comments towards resident Facility serving food that is not of quality

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with staff Susana and explained the reason for the visit as the Administrator was unavailable. Entrance interview. On 03/24/2022, the Department received a complaint regarding an allegation of sexual abuse – staff inappropriately touched resident. It was alleged that Staff #1 (S1) sexually abused Resident #1 (R1) by inappropriately touching R1’s breasts and vaginal area. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... On 03/25/2022, from 11:00am to 12:55pm, Licensing Program Analyst (LPA), Martha Guzman-Chavez conducted an initial complaint visit for the above allegation. The LPA met with Licensee Representative, Loretta Tiede and explained the reason for the visit. Additionally, the LPA interviewed the Licensee Representative at 11:25am and obtained copies of pertinent documents relevant to the investigation. On 08/09/2022, between 11:21am to 12:13pm, LPA Arroyo interviewed the Administrator, one staff, five residents, and observed the kitchen and food supply at 11:49am. On 03/28/2022, Investigator Real conducted an interview with R1’s resident representative; on 04/08/2022, with R1; and on 05/12/2022, with residents, Staff #1 (S1) and Staff #2 (S2). Additionally, Investigator Real reviewed facility file documents related to R1. A review of R1’s Appraisal/Needs and Services Plan, dated 01/27/2022, noted R1 is very difficult, upset and confused. R1’s physician report, dated 01/28/2022, listed R1’s primary diagnosis as right distal femur fracture. R1 was identified as being confused/disoriented yet able to follow instruction and communicate their needs. The report indicated R1 was not able to bathe, dress/groom, feed, or take care of their toileting needs. The resident appraisal, dated 01/31/2022, noted R1 as having a bad hurting hip and is in pain and confused. R1’s ambulatory status was listed as non-ambulatory and needed help with bathing, eating, and toileting. A notation indicated R1’s medication was needed and R1’s resident representative indicated they would get them. R1 moved into the facility on 01/28/2022. Prior to moving into the facility R1 had been in the hospital as a result of a fall at home. R1 sustained a femur fracture as a result of the fall. After being discharged from the hospital R1 went to the facility where R1 stayed for six days. On 02/03/2022, R1’s resident representative transferred R1 out of the facility as R1 was not happy at the facility. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Information obtained from the investigator’s interviews revealed R1 denied any sexual abuse by S1 or anyone else in the facility. R1 was in a lot of pain due to a recent fall that resulted in a fractured femur and did not want to me moved or touched. S1 was never alone with R1 and S1 always had another staff present when S1 was helping to reposition R1. R1 did not like being touched by S1 because R1 felt S1 was rough with them. R1 did not sustain any injuries by S1 or anyone else in the facility. R1’s resident representative reported R1 was in pain and R1 complained that S1 touched R1 “all over”. R1 did not disclose any specific location where they were touched. R1 never reported being touched on breast, vagina, or buttocks in a sexual manner. R1’s resident representative denied witnessing any abuse or neglect while visiting R1 in the facility. The residents interviewed did not report any problems, complaints, or abuse (sexual or physical). No residents reported S1 was rough when helping them move. S2 reported they were R1’s primary caregiver and S1 was never alone with R1. S2 changed R1’s diapers and bathed R1. S1 assisted by helping move R1 only when needed during diaper changes or when asked by S2. R1 was in a lot of pain due to the fractured leg and was very difficult and confused. R1 frequently complained of pain and did not want anyone to touch them. S1 denied the allegation and stated they only touched or moved R1 when assisting S2 as S2 was the primary caregiver for R1. S1 recalled R1 complained a lot and was in a lot of pain when R1 came into the facility after being discharged from the hospital. S1 tried to say nice things to R1 to make R1 feel better, but it was not helpful and R1 was confrontational. The information obtained during the investigation did not sufficiently support the allegation, therefore, the allegation “Sexual Abuse - Staff inappropriately touched resident” is deemed Unsubstantiated at this time. It was also alleged that staff made inappropriate comments towards resident. It was reported that S1 was calling R1 names such as ‘honey’ and ‘baby’ while living at the facility. Interviews conducted revealed R1 had been discharged from the hospital shortly before being admitted to the facility on 01/28/2022. Also, record review indicated R1’s primary diagnosis was right distal femur fracture. Due to the pain R1 was having while at the facility, S1 tried to say nice things to R1 to make R1 feel better; however, that did not help and R1 was confrontational. Report Continued on LIC 9099C... Report Continued from LIC 9099C... Correspondingly, interviews conducted with R1 revealed S1 was never in R1’s room by themselves. R1 also added that S1 did not say anything of a sexual nature to R1 while living at the facility. Interviews conducted with residents revealed that none of the residents have ever reported any problems or complaints amongst themselves regarding S1 or anyone else. Furthermore, residents stated they have not observed S1 harm or bother any of the residents in the facility. S2 reported S1 helps out mainly to reposition residents and S2 is always present as they work as a team. Based on the evidence gathered through interviews with residents, staff, and Administrator, there is insufficient evidence to support the allegation, ‘staff made inappropriate comments towards resident.’ Therefore, this allegation is deemed Unsubstantiated at this time. It was further alleged that facility is serving food that is not of quality. It was reported that food served at the facility was bad. During the visit on 08/09/2022, the LPA observed the kitchen and food supply. The facility had a variety of food including fruits, vegetables, milk, meats, eggs, and bread. Interviews conducted revealed facility staff go grocery shopping every Saturday. On Friday’s the staff clean out the refrigerator to make sure the food is still good and to make space for the new groceries that will be brought the following day. Items purchased every week usually consist of foods that residents enjoy as well as other items necessary to follow a certain dietary need. Although the facility does not have a specific menu to follow, the staff cooks every day and make sure it is something all residents will enjoy since it varies depending on each resident’s wants and needs. Furthermore, residents stated liking the food prepared for them and staff making good home cooked meals every day. Based on LPA observation and interviews conducted with the staff, residents, and Administrator, there is insufficient evidence to support the allegation, ‘facility serving food that is not of quality.’ Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview. . Report was reviewed with staff Susana and a copy of report was given.the state’s words, verbatim · CDSS document, Feb 16, 2023 · control 29-AS-20220325091634

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20220325091634). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation. During the complaint investigation of complaint # 29-AS-20220325091634, the following deficiency was observed: On 01/28/2022, Resident #1 (R1) was admitted to the facility. The Physician’s Report, dated 01/28/2022, lists R1 has having no capacity for self-care which is a prohibited health condition. The licensee did not submit an exception request to admit and retain a resident with a prohibited health condition. Exit Interview. Citation issued. Appeal Rights discussed. Report was reviewed with staff Susana and a copy of report was given.the state’s words, verbatim · CDSS document, Feb 16, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(5) · Plan of correction due date: Feb 16, 2023

Persons who require health services for or have a health condition…shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement is not met as evidenced by: Based on record review, the licensee admitted and retained R1 who had no capacity for self-care, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2023

Plan of correction: Administrator will submit memo of understanding that you have read and will comply with Title 22 Regulation 87615 Prohibited Health Conditions and 87616 Exceptions for Health Conditions and submit to CCL by 2/17/2023.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. Upon arrival, LPA met with Administrator Loretta Louise Tiede and explained the reason for the visit. Facility has (6) resident bedrooms and (3) bathrooms currently occupying (6) residents. (1) bedroom is designated for the staff. Fire extinguishers were observed fully charged and last serviced in October of 2022. Carbon / Smoke detectors were tested and observed to be operation during the time of the visit. All door alarms for exit ways were observed to functional during the visit as well. At approx. 11:00am, LPA toured the facility with Administrator The kitchen appeared to be relatively clean at this time and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in the top drawer to the left of the sink. Dining room furniture appeared to be relatively clean and functional at the time of the visit. At approximately 11:15am, LPA observed (4) residents having lunch at the dining table and (2) residents watching television in the living room. The living room was checked for cleanliness and furniture was checked for functionality during time of visit. Furniture appeared to be relatively clean and functional at this time. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Extra linen are kept in a cabinet in the hallway nearest bedroom #1. LPA observed a sufficient supply of linen and personal hygiene supplies stored at this location as well. Continued from 809 LPA observed bathrooms to be relatively clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom between 105 - 120 degrees Fahrenheit. Hallway closet by entry door was observed to store coats and other items for facility use. LPA observed a 30 day supply of PPE stored easily in multiple locations throughout the facility. Laundry area was located near bedroom #4. Laundry detergents, cleaning solutions and other toxins were observed to be kept in a locked cabinet inside the garage near the laundry area. The backyard of the facility has outdoor furniture with a shaded area with sufficient room for activities. LPA did not observe any obstructions to emergency exits at this time. The swimming pool was appropriately fenced and observed to be locked and secured. There was a detached storage unit and LPA observed it to store various holiday decorations. There was a storage room located on the upper left part of the facility. LPA observed it to store extra medical supplies and tools for facility use. The garage is attached to the home and observed to be locked and secured. The garage is currently being used as storage for additional non-perishable and frozen food, supplies, furniture and old/used equipment. The LPA spoke with Loretta regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate room #1 as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if there are any covid-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Exit interview conducted. Report issued and sent via email.the state’s words, verbatim · CDSS document, Nov 22, 2022