Villa-Care Home I

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melisa Rankin arrived at 9:22 a.m. to conduct a required 1-year annual visit. LPA met with Jessica Rust, Administrator. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: LPA toured resident rooms and observed that rooms were tidy and free of odor. The lighting and lamps are sufficient for the use of the facility and for resident comfort and safety. Toilet, hand washing and bathing facilities are operational and secure grab bars are present. The showers have slip resistant mats and/or flooring. The pathways are clear of any obstructions, there are raised concrete in the patio area that are scheduled to be leveled down. Disinfectants and cleaning solutions are inaccessible to residents in care and locked in closet. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The fire extinguisher was last charged and inspected on 12/8/25. The facility has smoke and carbon monoxide detectors that were tested and working properly. Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with resident rooms regarding the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 5 non-ambulatory residents and 1 bedridden resident. The facility currently has 3 residents. Staffing, Personnel Records & Training: The facility currently employs 4 staff and has 2 administrators who also provide caregiving coverage. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator Certificate expires on 10/05/26. Staff have annual training completed for various subjects/topics and hours for 2025. Medication training was completed. Continue on 809-C Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 3 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. All forms were legible, all records complete. Food Service: The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. The kitchen is clean and sanitary. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed 3 residents’ medications, no labels were altered, and no medications were expired. Residents with recent changes are being reviewed and will be communicated to LPA for clarification. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducted a quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility has 2 self-latch gate on side of the home. The facility does not have delayed egress, locked doors or gates. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Mar 4, 2026

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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin conducted an on-site 1-year annual visit to the facility above on 3/25/25 at 8:20 a.m. LPA met with Administrator and Licensee Jessica Rust and explained the purpose of the visit. LPA 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. KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of food, including emergency food supplies. Common areas: Living and dining room furniture were observed to be in good condition. The facility has Smoke detector(s) and a carbon monoxide detector which were working at the time of the visit. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 12/11/2024. The backyard has a covered outdoor area equipped with furniture for client use. Facility has open areas for visitors. No bodies of water noted. Restrooms: The resident restrooms were clean and sanitary and in operating condition with non-skid matts and flooring. Bedrooms: There are five (5) resident rooms, which were furnished as required. There is sufficient light for residents’ comfort. The door alarms that were tested were operational. Continued on 809-C Records: LPA reviewed resident and staff records. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete. LPA reviewed three (3) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. Files had all required documentation. All First Aid and CPR certifications are up to date and annual training is complete. MEDICATIONS: A sampling of medication was reviewed. The medications are centrally stored and locked in a cabinet in the living room. Medication and records are maintained according to regulation requirements. PRN authorization forms were found in resident files and PRN records are kept for each dose. EMERGENCY/DISASTER POSTING: Emergency numbers and procedures were posted, and drills are done quarterly. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 25, 2025

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not prevent a resident from falling and sustaining fractures while in care. Staff are sleeping during shifts.

Licensing Program Analyst (LPA) M. Rankin conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Jessica Rust and explained the reason for the visit. On 04/05/2024, the Department received a complaint regarding staff neglect and lack of supervision of R1 resulting in R1 sustaining a fracture from a fall while in care. The complaint also alleged staff were sleeping during their shifts. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Heidy Bendana. Continued on 9099-C Substantiated On 04/10/2024, from 9:35am to 11:00am, Licensing Program Analysts (LPAs) Rachael De Leon and Melisa Rankin conducted the 10-day complaint visit to the facility. LPAs De Leon and Rankin met with the Administrator and explained the purpose of the visit. The LPAs requested records pertinent to the investigation. LPA De Leon requested video footage for the dates of 03/29/2024 through 03/30/2024 for the camera located in the common area hallway and living room. The Administrator was informed the complaint was assigned to the Community Care Licensing Division (CCLD) Investigation Branch (IB) and that the investigator would return at a later date to complete the investigation. On 04/23/2024, from approximately 12:05pm to 1:17pm, the Department’s Investigators Bendana and Miles conducted interviews with the Licensee, Staff #3 (S3), and the Administrator; on 06/05/2024, at approximately 12:36pm, Investigator Bendana conducted an interview with R1’s resident representative; on 06/19/2024, at approximately 11:24am, Investigators Bendana and Miles attempted to interview R1, who was unable to be interviewed due to their dementia; on 08/22/2024, from approximately 12:28pm to 12:54pm, Investigator Bendana interviewed R1’s Primary Care Physician (PCP), and Witness #1 (W1). Staff #1 (S1) and Staff #2 (S2) were unable to be interviewed due to moving out of the country. In addition, the investigator reviewed Marian Regional Medical Center records, Wilshire Home Health records, RING camera video footage, photos of sensor and alert system of R1’s bedroom, and other facility file documents related to the investigation. According to the facility file documents reviewed R1 was admitted to the facility on 02/17/2020. The Preplacement Appraisal Information, dated 02/17/2020, listed R1 needed to use a cane or four-wheel walker with seats and brakes. Continued on 9099-C R1’s gait was slow with right leg externally rotated. R1 was diagnosed with dementia and showed signs of confusion/disorientation, sundowning behavior and can follow directions. The most recent Physician’s Report, dated 07/03/2023, listed R1’s primary diagnosis as anxiety disorder, Parkinson’s disease, and hypothyroidism. The secondary diagnosis listed atherosclerotic heart disease of native coronary artery without angina pectoris, restlessness, agitation, and hallucinations, and dementia. R1 had visual impairment, was confused/disoriented with inappropriate behavior, and needed assistance with Activities of Daily Living (ADLs) which included assistance with toileting. It was documented that R1 could transfer independently to and from bed but also indicated R1 was non-ambulatory. R1 had previously sustained a fall at the facility in April 2022, which resulted in a hip fracture. The Appraisal/Needs and Services Plan dated 02/01/2024 documents R1 had a recent stroke and now ambulates and communicates slower. The Plan also documents R1 as having more signs of confusion, forgetfulness, slow getting around but uses walker or wheelchair, and indicates staff assist with mobility. On 03/07/2024, R1 presented to the Marian Regional Medical Center Emergency Department with the chief complaint of unresponsiveness. The records documented R1 had a known history of acute ischemic stroke, dementia, Parkinson’s, hyperlipidemia, hypothyroidism, iron deficiency, chronic constipation. The Emergency Medical Services (EMS) reported R1 resided at the Villa Care Home, was last seen normal at approximately 11:15am, eating. R1 was then seen slumped over on the couch, staff lowered R1 to the ground and called EMS. EMS noted a right-sided facial droop, low blood pressure and administered IV fluids R1 was admitted for further evaluation and discharged on 03/08/2024 with discharge instructions for fall prevention and ongoing physical and occupational therapy. The hospital Occupational Therapy assessment noted R1 was dependent on toileting and unable to complete toilet transfers due to weakness and symptoms of light headedness. Continued on 9099-C The discharge diagnosis listed fall with possible unwitnessed brief syncope (fainting), and states Patient should have very close standby assist. No records show that R1’s appraisal/needs and services plan was updated after this change in condition to align with hospital records showing R1 needed additional supervision and assistance. The review of the Unusual Incident/Injury Report submitted by the facility for R1 listed the date of incident as 03/29/2024. The report documents at approximately 1:30am, S1 and S2 heard a loud noise in R1’s room. S1 and S2 found R1 on the floor with an excessive amount of blood coming from R1’s nose. S1 and S2 called 911 immediately and R1 was transported to the hospital. R1 was discharged with a broken nose and UTI. Actions taken or planned were to make sure R1 had motion alarms set in R1’s room and encourage water intake and for R1 to take R1’s prescribed medications. The report also indicated that R1’s resident representative was notified of the incident by the hospital. According to the Marian Regional Medical Center records, R1 arrived at the Emergency Room on 03/29/2024 at 2:48am, with a chief complaint of fall/nosebleed. The fall was noted to be an unwitnessed fall. The paramedics stated R1 was found lying on the ground. Per facility staff, R1 was acting to R1’s baseline. R1 stated R1 believed they fell coming back from the bathroom because their feet slipped out from underneath them. R1 stated they did not fully remember the event. R1 was found bleeding from the nose and a small hematoma to R1’s forehead. X-rays were taken and results showed left frontal scalp swelling without underlying skull fracture or acute intracranial findings, comminuted nasal bone fracture with soft tissue gas and minimal deviated anterior nasal septum. R1 was negative for acute cervical spine findings. R1 likely has nasal bone fracture without evidence of significant deformity or septal hematoma. R1 complains of tenderness to the knee. The final diagnosis for R1 were closed head injury, nasal bone fracture, epistaxis (nosebleed), pituitary adenoma, and UTI (urinary tract infection). Continued on 9099-C The information obtained from the interviews, incident reports, and medical records indicated R1 sustained an unwitnessed fall on 03/29/2024. During the interviews, the Licensee and the Administrator provided inconsistent statements. The Administrator reported there had “never” been any falls at the facility, then reported R1 had sustained a fall where R1 “broke” their hip. The Administrator stated R1 was a fall risk and had an unsteady gait. The Licensee reported R1 was a fall risk and had fallen during the night. The Licensee explained S1 and S2 found R1 on the floor laying on R1’s stomach. The Licensee revealed R1 had a motion sensor alarm located perpendicular to R1’s bed, on the floor. The Licensee assumed the motion sensor alarm was turned on. Facility staff gave inconsistent statements of how often resident checks are conducted. Per S3, resident checks are conducted every four hours. The Licensee stated the checks are conducted frequently, they should be every hour or every couple of hours. The Licensee and the Administrator reported two (2) staff worked the night shift 7:00pm to 7:00am; however, the facility personnel report dated 02/02/2024 only listed S2 working the night shift. Consequently, the RING camera located near the facility’s front door facing the living room did not capture activity or movement from 7:00pm on 03/28/2024 to 1:57am on 3/29/2024. Per the RING camera footage, the EMS and firefighters arrived at the facility at 2:20am and were taken down the hallway leading to R1’s room. R1’s resident representative was told R1 fell out of R1’s bed and that the sensor alarm went off after R1 fell. The facility knew R1 was a fall risk and needed assistance with ADLs including toileting. Based on the evidence obtained, the Department determined that it is more likely than not that the caregivers were asleep and did not conduct checks on residents thus neglecting and lacking supervision. Continued on 9099-C The facility staff neglect and lack of supervision resulted in R1 sustaining a fractured nose while in care; therefore, both the allegations “Staff failed to supervise Resident #1 (R1) resulting in R1 sustaining fractures from a fall while in care” and “Staff are sleeping during shifts” are deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Sep 30, 2024 · control 29-AS-20240405155913

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312 · Plan of correction due date: Oct 1, 2024

§1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when due to a lack of supervision by staff, R1 sustained a fall resulting in a fractured nose, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2024

Plan of correction: Licensee will submit a plan how you will ensure appropriate care and supervision to meet the needs of residents. Submit to CCL by 10/1/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 14, 2024

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents…shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when staff were sleeping and not conducting regular checks, R1 sustained a fall resulting in athe state’s words, verbatim · CDSS document, Sep 30, 2024

Plan of correction: Licensee will submit a plan, including a current LIC500 Personnel Report, showing how you will ensure adequate staffing for all shifts to meet the needs of residents. Submit to CCL by 10/1/24 fractured nose, which posed an immediate health and safety risk to residents in care.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) M. Rankin conducted a Case Management - Deficiencies visit to deliver findings. LPA met with Jessica Rust Administrator and explained the reason for the visit. During the Department’s investigation of complaint #29-AS-20240405155913, the following deficiency was observed: On 03/29/2024, at approximately 1:30am, Resident #1 (R1) had an unwitnessed fall and sustained a fractured nose. Interviews and review of the Unusual Incident/Injury Report submitted by the facility revealed R1’s resident representative was notified of the incident by the hospital. Citation issued, exit interview, appeal rights given.the state’s words, verbatim · CDSS document, Sep 30, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(8) · Plan of correction due date: Oct 14, 2024

87468.1(8) Personal Rights of Residents in All Facilities (8)To have their representatives regularly informed by the licensee of activities related to care...as appropriate to their needs. This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. The facility did not notify R1’s resident representative of R1’s fall on 03/29/2024, which posedthe state’s words, verbatim · CDSS document, Sep 30, 2024

Plan of correction: The licensee will submit a plan describing how you will ensure resident representatives are notified of resident change of condition. Submit proof to CCL by 10/14/24. a potential health and safety risk to residents in care.

Type of visit: Required - 1 Year

On 03/27/2024, Licensing Program Analyst (LPA) Brian Phillips arrived unannounced for an unscheduled visit to conduct a required Annual site inspection visit at the facility above. When the LPA arrived, they were greeted by Administrator Jessica Rust, and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of Six (6) Non-Ambulatory residents, of which One (1) may be bedridden in Room #4 only. The residents have an age range of sixty (60) years of age and older. The facility has an approved Hospice Waiver for Six (6) Residents. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio area with furniture and shade. KITCHEN: The facility maintains kitchen room/area for the facility that is open to include a dining room area. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents in the garage of the facility. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. Items that could constitute a danger to residents are kept inaccessible to residents outside of the kitchen area. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. Continued on 809-C The kitchen contained a sufficient supply of dishes, glasses and utensils. There is space to lock chemicals under the kitchen sink. COMMON AREAS: The indoor areas of the facility consists of resident bedrooms, restrooms, shower areas, a Centrally Stored Medication area, kitchen, dining room, storage area closets/rooms, living room, Staff room/area and an entrance area upon entry into the facility. At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. There are no fireplaces in the facility. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector(s) were operational at the time of the visit. The facility has a fire extinguisher that was fully charged and serviced annually, being tagged as serviced in 2024. This facility contains a locked centrally stored medication containment area/closet, extra storage areas for additional perishable food, closets/rooms in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for resident personal hygiene equipment constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the residents such as television, puzzles, games, etc. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use. The laundry area for the facility is located in the garage of the facility that is inaccessible to residents. There is a main entrance walkway into the facility and an administrative entrance area for visitors. The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair. A locked medication closet inaccessible to residents and First Aid Kit were observed to be complete. OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of cement walkways and grass areas. The facility outdoor front yard area is paved with a walkway up to the front door of the facility. The back yard has a patio with shade and outdoor furniture conducive for outdoor visitation. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The exterior of the facility has a closed perimeter which consists of a fence around the backyard area of the facility. Inside of the perimeter is the outdoor/outside activity area for residents with a patio in the backyard, furniture, shade. The facility has an outdoor activity area that is provided with a shaded area and furnished for outdoor use. There are no bodies of water noted on the facility property. Continued on 809-C The designated laundry area is in the garage of the facility, which is also the area where locked storage of cleaning products and any toxins/chemicals that could constitute a danger to residents are stored, which are kept locked and inaccessible to residents. Staff members are the only individuals allowed to do laundry and the garage is inaccessible to residents. There was emergency food and water in the garage of the facility and in the extra perishable food storage area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. LPA did not observe any noticeable outdoor hazards in areas accessible to residents. The building and grounds are free from hazard and the facility has flash lights and batteries. BEDROOMS: The facility has Five (5) resident bedrooms, both individual bedrooms for one (1) resident and shared bedrooms for two (2) residents. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. All resident bedrooms were furnished and contained beds, chairs, bedside tables and lamps. All beds have sheets, pillows, and mattress pads. There is also an ample supply of linens and towels. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has a single bed or beds, nightstand, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. All resident bedrooms have sliding doors into the backyard of the facility, monitored by auditory alarms if the sliding doors are opened to alert the Staff members of the facility. RESTROOMS: There are three (3) resident restrooms in the facility. Two (2) of the restrooms are specifically for resident use, while one (1) restroom is used primarily by Staff members/caregivers. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms/showers inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. The restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. Nightlights are installed in the hallways outside of the resident restrooms. Continued on 809-C All resident restrooms consist of a sink and toilet, while the resident shower/bathing areas consist of a shower and/or bathing area with grab bars and non-skid surfaces. LPA observed night-lights present in the main hallway. One of the resident restrooms has a call button located on a grab bar next to the toilet in case any resident requires immediate assistance from the Staff. RECORDS: The facility keeps confidential storage of both resident and Staff member records on-site at the facility. Staff member records were reviewed for, but not limited to Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education, and experience, approved Certification for the Administrator, verification of first aid training, Criminal Record Statement, Criminal Record Clearance/Exemption, Verification of Staff training, Employee Rights, and Abuse Reporting Requirements. All staff members’ personnel records reviewed by LPA had the appropriate documentation. The administrator of the facility has a Pending Residential Care Facility for the Elderly (RCFE) Administrator Certificate from a previously Active Administrator Certificate, with payment received. Resident records were reviewed for, but not limited to Pre-Admission/Placement appraisals, Resident Appraisals, Appraisal Needs and Services Plan (ANS), Physicians’ Report for RCFE, Identification and Emergency Information, Current Admission Agreement with signatures, Personal Rights for Residents, Record of Residents safeguarded cash resources and/or Record of Resident personal property/valuables, Physician Orders for Life Sustaining Treatment (POLST), Responsible Person or Conservator of Resident, Self-management of medications if applicable, Medication Orders, and Medication Logs. Additionally, the facility keeps records of resident(s) weight as well as resident dietary restrictions. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. MEDICATIONS: The facility maintains a locked centralized storage area for resident medications. Centrally Stored Medications are in a locked storage containment area within an indoor closet area of the facility, which remains locked at all times, inaccessible/locked to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record, and the record of Controlled Medications. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. Continued on 809-C INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. 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. The facility’s policies and procedures as it pertains to infection control are adequate. FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility keeps posted copies of facility documentation such as the RCFE License Certificate, LIC 500 Personnel Report, Documentation of Facility Waivers, Plan of Operation, Emergency Disaster Plan for Residential Care Facilities for the Elderly (RCFE), Facility Infection Control Plan/Mitigation Plan, Certificate of Liability Insurance, Valid Administrator Certificate, and a Facility Sketch. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. No deficiencies cited. Exit interview conducted. A copy of the report was issued to the facility.the state’s words, verbatim · CDSS document, Mar 27, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Olson conducted a Case Management - Incident visit to issue deficiencies on an incident the facility self reported. LPA met with Administrator and Licensee and explained the purpose of the visit. LPA toured the facility with Administrator. CCL received an incident report on 12/7/23 stating that on 12/4/23 a hospice staff observed Staff 1 (S1) used unnecessary roughness or unnecessary force to ensure Resident 1 (R1) remained in a recliner chair as they attempted to get up out of the chair. The incident report states hospice personnel contacted the Licensee to notify them of the incident, and S1 was terminated by the Licensee. LPA interviewed Licensee who stated they reviewed the video footage of the common areas in the facility, and observed S1 “shove/push” R1 back into the recliner. Licensee stated they decided to terminate S1 based on the actions. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). An exit interview was conducted, a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jan 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 27, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirment was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the section cited above when Staff 1 did not treat R1 with dignity by shoving them, which posed an immediatel personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Administrator conducted a personal rights training with the Long Term Care Ombudsman on 12/13/23 and 12/14/23. POC is cleared druing the visit.