Valley Christian Home

Allegation investigated: Staff do not ensure resident rooms are cleaned adequately.

On 07/31/23, Licensing Program Analyst, (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegation. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility. During the investigation, LPA reviewed records that include R1's admission agreement, needs and service plan, facility's cleaning schedule, and staff's cleaning duties. Page 2 (#13) of the signed Admission agreement dated 09/06/22, shows "cleaning of resident's room", as a basic service but is not itemized. LPA observed a cleaning duty checklist for the Housekeepers. Checklist shows daily duties Monday- Friday, weekly duties and monthly duties. "Deep Vacuuming" of room, to include furniture and under the bed, are listed as a monthly duty. (Continued on 9099-C) Unsubstantiated (Continued from 9099) It is noted on the checklist, that housekeeping services are always provided in cases where accidents or messes need immediate attention. Facility has 2.5 housekeepers Monday through Friday, and care providers perform daily duties on Saturday and Sunday. LPA toured R1's room and observed the room to be clean and free from odor. R1 stated their bed was not purchased by the facility, but brought from home. LPA observed R1's bed to be larger than the average facility twin bed that is provided to residents. R1's bed has a fabric chest attached to the foot of the bed that does not allowed the bed to moved. LPA toured the facility housekeeping storage room where the facility vacuum's are located. Vacuums were observed to have a detachable wand for hard to reach areas. LPA observed additional resident rooms to have twin beds provided by the facility. Interviews with Administrator state the facility was unaware of any concerns of uncleanliness, as this was never brought to the attention of staff and/or Administration. Although the allegation may have happened, there is not a preponderance of evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Exit interview conducted and copy of report was provided to Administrator. No deficiencies cited. .the state’s words, verbatim · CDSS document, Jul 31, 2023 · control 24-AS-20230622094343

Allegation investigated: Staff yelled at resident

On 7/27/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced complaint visit. LPA met with Administrator, Erin Alvidrez, introduced self and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in common areas and in rooms. During complaint interviews were completed with staff and residents and personnel files were reviewed. Interivews conducted do not support the allegation listed above. Although the allegation may or may not have occurred, it does not meet the preponderance of evidence standard per Title 22. The allegation listed above is UNSUBSTANTIATED. Exit interview completed with Administrator, Erin Vldirez. A copy of this report was given. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 27, 2023 · control 24-AS-20230227085040

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff do not maintain HVAC unit in good repair Staff do not maintain a comfortable room temperature for resident

On 7/27/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced complaint visit. LPA met with Administrator, Erin Vlidrez, introduced self and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in common areas and in rooms. During the complaint LPA completed interviews, observed air conditioner filters/vents and thermostats and temperatures in residents’ rooms. Upon tour of facility 10 rooms and 6 thermostats were checked. 9 of 10 rooms ranged between 71 to 74 degrees F. R1’s room was at 78 degrees F. Outside temperature was 54 degrees F at time of visit. Thermostats were all set to the same temperature. The preponderance of evidence standard has been met and the allegations listed above are SUBSTANTIATED per Title 22.the state’s words, verbatim · CDSS document, Jul 27, 2023 · control 24-AS-20230227085040

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

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidence by: LPA observation that 9 of 10 rooms check had a cooler temperature than that of R1. Temperatures ranged from 71 to 74 degrees F. Where R1’s temperature read at 78 degrees F. LPA overheard R1 inform staff it “was hot in their room” and staff failed to adjust their room temperature to make R1 more comfortable. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator stated fans were offered, temperature changed on thermostat per R1 request as needed. In service training to be completed with all staff. Copy of in-service sign in sheet and training material to be provided to CCL by POC

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Aug 4, 2023

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidence by LPA interviews and observations: interviews disclosed maintenance is not completed unless there is an issue with a unit. Observation of air conditioner filters showed they had not been changed. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator stated filters are being changed approximately every 2 months and more frequently as needed. In service training to be completed with all staff. Copy of in-service sign in sheet and training material to be provided to CCL by POC

Type of visit: Case Management - Deficiencies

On 7/27/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced case management visit. LPA met with Administrator, Erin Alvidrez, introduced self and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in common areas and in rooms. During a previous complaint visit made on 3/6/2023, an interview was completed with Administrator. Upon touring facility, it was observed that one of the thermostats reviewed was observed to be at a higher temperature than the rest. (78 degrees F). The resident that resided in this room was overheard stating “it was hot” and "I can not open the window can I" to which Administrator responded "no". When asked why R1 was not able to change the thermostat to make their room more comfortable, the Administrator stated it was because it would change the temperatures in other rooms ran off that thermostat. When asked why R1 could not open their window, Administrator stated it was due to it changing the reading of the thermostat located in their room. This violates the personal rights of the residents in care. Deficiency cited on 809D per Title 22. An exit interview was completed with Administrator, Erin Alvidrez. A copy of this report and appeal rights given.the state’s words, verbatim · CDSS document, Jul 27, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 4, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: LPA observation of 6 or 6 thermostats set to the same temperature. R1 was overheard by LPA of them informing staff it “was hot in their room” and they “open their window” and staff saying “no”. Staff failed to adjust their room temperature or open a window to make R1 more comfortable. This poses a potential health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator stated fans were offered, temperature changed on thermostat per R1 request as needed. Filters are being changed approximately every 2 months and more frequently as needed. In service training to be completed with all staff. Copy of in-service sign in sheet and training material to be provided to CCL by POC

Allegation investigated: Staff does not treat resident with dignity and respect Staff refuse to provide resident with assistance

On 07/11/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Care Coordinator, Karen Beasley Based on interviews conducted with staff and residents, the allegations: Staff does not treat resident with dignity and respect and Staff refuse to provide resident with assistance are unsubstantiated. 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. No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Care Coordinator, Karen Beasley, whose signature on this form confirms receipt of this document. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 11, 2023 · control 24-AS-20230613081923

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 5/4/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA met with Administrator Erin Alvidrez. LPA introduced self, stated the purpose of the visit. LPA toured facility with Administrator. LPA toured inside and outside of the facility. Facility has three wings: north, south, west wings, 3 dining areas, and a kitchen. Facility also has a salon, library, and activity's room. The facility was observed to be at a comfortable temperature, odor-free, and in good repair. There were no obstruction or fire clearance related issues. The fire extinguisher was observed throughout the facility with a service date of: 12/21/22. An adequate supply of linens and personal hygiene products were observed. Bedrooms were observed to have adequate lighting and required furniture and bedding. Bathrooms were properly equipped with non-skid surface/mat, securely fastened grab bars, and trash can with lids. Hot water temperature was tested at 113.5 to 115.1 degrees F. An adequate supply of perishable and non-perishable food was observed. Food was observed to be properly labelled and stored with a sufficient supply. Medications are kept in a locked Med Room. A sample of residents’ MARS was reviewed. Outside was toured and observed free of debris. There are no bodies of water of the premises. A sample of residents’ file reviewed to have update Emergency contacts, Admission agreement, Pre-Appraisal form, and physician report. A sample of staff's files were also reviewed to have current First Aid/CPR, fingerprinted clear and associated to the facility. No deficiencies issued during this inspection. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 5/10/23. The following updated forms were requested: Lic 308, Lic 309 (if applicable), Lic 500, Lic 610E, Lic 9282, and current Administrator certificate. A copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, May 4, 2023

Type of visit: Required - 1 Year

On 6/23/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA met with Administrator Erin Alvidrez and stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point. Facility staff observed with facial coverings. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. Bedrooms are single occupant. Food supply was checked and there appeared to be an adequate supply. Fire extinguisher in kitchen was last serviced on 5/4/2022 and was fully charged. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Staff records were reviewed for good health. No deficiencies were observed. LPA is requesting the following documents be submitted to the Fresno CCL office by 6/30/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020. An exit interview was conducted with Administrator. Report signed on-site and printed copy provided.the state’s words, verbatim · CDSS document, Jun 23, 2022