Vintage House

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator, Francisco Roa was unable to come to facility but was available by phone and gave permission for staff to sign report. LPA initiated a tour of the facility around 10:30am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathroom used by residents measured at 108.6 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility does not have adequate emergency food and no emergency water supplies. Fire extinguishers were last serviced August 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Four staff files and four resident files were reviewed. Staff do not have required First Aid and CPR certificates or updated training records. Administrator Certificate for Administrator, Francisco Roa, 6005473740 is on the Department's pending list. Medication records were reviewed. Continued on LIC 809C Continued from LIC 809 Licensee/Administrator to submit updates of the following documents by 11/24/2023: LIC 500 Personnel Summary Copy of Liability Insurance LIC 610 Emergency Disaster Plan (If any changes) Infection Control Plan (If any changes) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Oct 24, 2023

Allegation investigated: Facility staff refused to take resident back after a hospitalization.

Licensing Program Analyst Bertozzi arrived unnaounced to deliver findings regarding the above complaint allegation and met with Caregiver, Renee Johnson Bernabe. Licensee/Administrator was available by phone. Complaint alleges that resident was diagnosed with Covid while at the hospital and facility refused to bring resident back to the facility. Per interviews, the hospital initially agreed to keep the resident for twenty days but later agreed to isolate the resident in the hospital for ten days. Interviews revealed that Licensee refused to bring resident back until resident tested negative on a Covid test. Per Licensee, the resident was in a shared room and they were unable to isolate them but other interviews revealed that facility did have a vacant room that could used as an isolation room. Continued on LIC9099C Substantiated Continued from LIC9099 The allegation that Facility staff refused to take resident back after a hospitalization is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Jun 2, 2023 · control 21-AS-20230418084833

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 3, 2023

(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.., Based on interviews, Licensee did not meet requirement by not accepting a resident back from the hospital. This is an immediate risk to personal rights.the state’s words, verbatim · CDSS document, Jun 2, 2023

Plan of correction: LPA discussed with Licensee that facility may not refuse bringing a resident without a prohibited health condition back to the facility once discharged from the hospital. Deficiency is cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/22/2022 to conduct a Required - 1 Year inspection. This inspection was focused on the infection control practices and procedures of this facility. LPA was initially greeted by staff. Administrator, Francisco Roa arrived shortly. LPA toured building and grounds which were clean and in good repair. Exits and walkways were free from obstructions. Facility has a total of 4 bedrooms, 2 of which are shared. There are currently 4 residents in care. Current census allows for isolation of residents if necessary. Resident bathrooms have necessary grab bars and non-slip mats. Resident bedrooms were furnished per regulation. LPA observed operational CO and smoke detectors throughout the facility. Facility had a sufficient supply of perishable and non-perishable food. Toxins were kept locked and secured. Medications were centrally stored and inaccessible to residents in care. Facility had a supply of extra linens and towels for residents. LPA reviewed 3 staff files and 3 resident files. LPA and administrator discussed ongoing training requirements for staff. LPA and administrator discussed when it is necessary to request updated physician's reports. All staff and residents are fully vaccinated. Administrator is working with public health to schedule the third booster shot. LPA is requesting the following documents be submitted within 30 days of the inspection: LIC 500 Personnel Report LIC 610 Emergency Disaster Plan LIC 9020 Resident Roster LIC 308 Designation of Facility Responsibility Evidence of Liability Insurance No deficiencies cited during today's inspection. Exit interview conducted with administrator and a copy of this report printed for the facility.the state’s words, verbatim · CDSS document, Sep 22, 2022

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Case Management - Annual Continuation Infection Control inspection to this facility and met with staff Catalina Sanchez & Renee Johnson. Facility has 4 residents present with 1 resident under Hospice care at this time. During facility tour on 9/29/2021 with staff Renee Johnson, facility was found to be clean and at a comfortable temperature. Bedroom 4 has a long hospital bed that per staff will be removed to allow residents to exit through the door if needed in case of emergency. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 9/2021. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. There was a supply of PPE available. Facility has a closet door and two window shades in the garage that facility will be installing on facility. Department is requesting submission of pictures showing that bed has been removed - smaller bed in place is OK, closet door and window shades installed by 10/6/2021. In addition, documentation below requested by 9/27/2021 still pending to be submitted to the Department: LIC 308 Designated Administrator LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 610E Supplemental Emergency Disaster Plan for RCFE LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Copy of Liability Insurance No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Sep 29, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Catalina Sanchez. Facility has 5 residents present with 1 resident under Hospice care at this time. Facility offers activities cards, reading, exercises, outside walk, and etc. During facility tour on 9/20/2021 with staff Catalina Sanchez, facility was found to be at a comfortable temperature. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Sample test of Smoke Detector & Carbon monoxide detector were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Facility understands that hot water temperatures must measure within Title 22 acceptable regulations of 105 to 120 degrees F. Infection Control: Facility has submitted a mitigation program plan that has been approved. Facility has posters that placed at facility. At this time facility is planning to have at entrance a table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility doesn’t have enough PPE supplies stored in the facility. Facility has admitted new residents since COVID-19. Residents medications are stored and locked in a locked medication closed in the entrance of the facility. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility, however; staff stated that they are sometimes able to wear masks when going on outings. All staff had masks on during this visit. Continued LIC809-C In addition, facility has a designated area for visitors which are being allowed for visits. Residents also have available video and telephone calls when contacting with family members and others. Staff had all PPE training required on file and facility is working towards obtaining N-95 fit testing. In addition, LPA advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32 & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19). In addition, LPA had a discussion with administrator regarding visitation guidelines per PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19). This visit will need to be continued at another day. LPAs reviewed Licensing Information System (LIS) with staff who stated that is correct and updated at this time. No deficiencies cited during this inspection. Department is requesting the following updated documents to be submitted to CCLD by 9/27/2021: LIC 308 Designated Administrator LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 610E Supplemental Emergency Disaster Plan for RCFE LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Copy of Liability Insurancethe state’s words, verbatim · CDSS document, Sep 20, 2021

The state marks this report as 9 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.