Westmont of Chico-The Inn

Type of visit: Required - 1 Year

On 10/26/2023 Licensing Program Analyst (LPA) Jaynae Boyles arrived unannounced to conduct a required annual inspections. LPA met with Administrator Cliff Keene and explained the purpose of the visit. LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: interior of the facility, including (10) private resident rooms, restrooms, kitchen, library, Arts & Crafts Room, Bistro, Fitness Center, Game Room and Mammoth Theater Room and common areas. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 115 degrees F. Each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, and trash can. LPA checked the kitchen area for the ability to prepare and store food. Facility has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector. LPA observed fire extinguishers located on all levels of the facility, which were last serviced on 09/18/2023. LPA observed hand sanitizers to be located throughout the facility. LPA reviewed (5) resident files and also reviewed (5) staff files. LPA observed the facility to be clean, in good repair and odor free. In the areas toured no immediate health, safety, or personal rights violations were observed. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Oct 26, 2023

Type of visit: Case Management - Legal/Non-compliance

04/20/2023 09:30 AM Licensing Program Analyst (LPA) Rebecca Knight made an unannounced visit to the facility and met with Resident Services Director Wendy Anderson. The purpose of this visit was to confirm that the facility had posted a notification of The Department’s intent to revoke the facility license. Ms. Anderson stated the notice was posted in the facility near the mail boxes on 03/14/2023. LPA observed the posting during the visit and confirmed the posting contained all required elements contained in Health & Safety Code 1569.38 Posting of licensing reports; disclosure to new residents. During the visit LPA requested a copy of the posting, and the letter that was mailed out to all residents and their responsible parties on 03/14/2023. LPA also obtained a list of telephone numbers for resident’s responsible parties. No deficiencies cited. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 20, 2023

Type of visit: Case Management - Other

On 02/28/23, Licensing Program Analyst Donna Gurriere conducted a case management visit to follow up on a substantiated complaint allegation of failure to seek timely medical attention and resident sustained serious injuries due to lack of care and supervision. LPA Gurriere met with Administrator Cliff Keene and explained the purpose of the visit. On September 15, 2022, the Department concluded a complaint investigation for allegations that Resident sustained serious injuries due to a lack of care and supervision and facility failed to seek timely medical attention. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation, including medical records. On March 22, 2022, at 2:59 p.m., Resident 1 (R1) was found on the floor of R1’s apartment after sustaining an unwitnessed fall and was transported to the hospital. A review of medical records revealed R1 sustained a closed fracture of R1’s right distal femur (noted “as consequence of the fall”) and had an unstageable, full thickness pressure wound on R1’s right buttock. R1 sustained healing abrasion on R1’s right elbow and left forearm and a deep tissue injury on R1’s left heel. The Wound Care Registered Nurse (RN) assessed and found R1’s wounds to include the healing properties/scabbing of the elbow and forearm abrasion consistent with wounds that are 1 to 2 days old. continued This Department determined staff neglected R1 by failing to supervise R1 appropriately and failing to check on R1 as needed per facility’s policy. The Department found staff were falsifying information on the Resident Meal Checklist. Staff marked R1 was present for breakfast, lunch and dinner on March 21, 2022. Due to the falsified records, staff did not check on R1 resulting in a delay of medical treatment for an unwitnessed fall. Per facility key fob records, R1 entered their room on March 20, 2022, at 2:56 p.m. and R1 never left the room until discovered on March 22, 2022, at 2:59 p.m. Key fob records indicate the last request for exit was on March 19, 2022, 8:07 p.m., and 13 additional “Request for Exits,” between 9:18 a.m. and 9:42 p.m. that day, by either R1 or a staff member. Records show that R1 last opened the door to exit on March 19, 2022 at 8:07 pm, however, the Maintenance Director explained, this does not mean that R1 necessarily left the room, but rather could have opened the door as if to exit. Maintenance Director and staff stated that R1 tended to open the door and peek out, but not actually exit. On March 20, key fob records indicate “No registered Request to Exit for entire 24-hour period, and no registered Passage for R1 for an entire 24-hour period.” R1 sustained an unwitnessed fall in R1’s room during this time period. R1 was discovered in R1’s room on March 22, 2022, at 2:59 p.m. when staff smelled “a really rancid urine smell” coming from R1’s room, which prompted staff to check on R1. Staff discovered R1 lying on the ground on their left side in a pool of urine. When R1 was found, it was documented R1 was not at baseline and staff contacted 9-1-1. R1 was admitted to the hospital and diagnosed with a broken bone, pressure injuries and abrasions. Paramedics and medical staff (nurse and doctor) provided statements to support that the injuries were 1-2 days old. Medical records reviewed shows blood work indicated R1 was incapacitated for at least 8 hours which is evidence that R1 sustained the pressure injuries as a result of lying in a position for a prolonged period of time. continued The preponderance of evidence supports that R1 did not receive timely medical attention due to staff falsifying records which resulted in neglecting to check on R1. The above allegations were substantiated on September 19, 2022, and deficiencies were cited for violating the following California Code of Regulations (CCR) Title 22: Section 87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities: In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. Section 87464(1) Basic Services (f) Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). An immediate civil penalty in the amount of $500 was issued for a violation of Section 87464(1), and the license was informed that an additional civil penalty was still being determined and may be assessed based on Health and Safety Code Section 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by R1 sustaining pressure injuries, abrasions, and a broken bone from an unwitnessed fall that required hospitalization. Medical records and statements further determined that R1 was incapacitated for a prolonged period of time in which R1 did not receive timely medical attention. continued Today, 02/28/23, the Department will be issuing a civil penalty per Health and Safety Code Section 1569.49(f) in the amount of $10,000 for a violation the Department constitutes as a serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on September 15, 2022, the amount of the civil penalty issued today will be $9500. A copy of the LIC 421D was given to the facility representative. Exit interview conducted. Appeal Rights provided. A copy of the report issued. Signature on these reports acknowledges receipt of these rights, found on page 2 of LIC 421D.the state’s words, verbatim · CDSS document, Feb 28, 2023

Type of visit: Case Management - Incident

On December 29, 2022, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management visit. LPA met with Executive Director, Cliff Keene, and explained the purpose of the visit. LPA wore a surgical mask and were screened by facility staff prior to entering the facility. The purpose of the visit was to follow-up on an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 11/13/2022. The report indicates resident's (R1) family transported R1 to the hospital to get evaluated due to having multiple falls without injuries and having increase confusion. R1's responsible party notified the facility R1 will be staying at the hospital. LPA requested for R1's Physician's Report, Reappraisal, Level of Care Assessment, and medical discharge documents, and fall prevention training. R1 returned to the community and is doing well. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Dec 29, 2022

Type of visit: Case Management - Incident

On December 29, 2022, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management visit. LPA met with Executive Director, Cliff Keene, and explained the purpose of the visit. LPA wore a surgical mask and were screened by facility staff prior to entering the facility. The purpose of the visit was to follow-up on an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 12/07/2022. The report indicated resident (R1) lost her balance and had a fall witnessed by staff. R1 complained out left hip pain. R1 was transferred to hospital for evaluation. R1's responsible party were notified by the facility. R1 was diagnosed with fall, contusion of food, head injury, and contusion of hip. R1 returned to the community the same day with no new orders. R1 placed on alert charting 48 hours to monitor. LPA requested for R1's Physician's Report, Reappraisal, Level of Care Assessment, and medical discharge documents, and fall prevention training. R1 returned to the community and is doing well. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Dec 29, 2022

Type of visit: Required - 1 Year

On 10/29/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual. LPA met with Resident Services Director, Wendy Anderson, and explained the purpose of the visit. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and additionally, LPA was screened per COVID-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Resident Services Director confirmed there is (1) resident on hospice services, facility has a hospice waiver of 10. LPA and Resident Services Director toured the interior of the facility, including (1) private resident rooms, restrooms, kitchen, laundry room, medication room, library, Arts & Crafts Room, Bistro, Fitness Center, Game Room and Mammoth Theater Room and common areas. LPA observed it to be clean, in good repair and odor free. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Resident Services Director completed the infection control domain and facility was found to be in compliance at this time. LPA observed sufficient 2+day perishable and 7+day non-perishable food. LPA observed hand sanitizers to be located throughout the facility. LPA observed fire extinguishers located on all levels of the facility, which was last serviced on 09/16/2022. LPA observed restrooms to have handwashing signs, paper towels, soap and trashcan with lid. LPA observed and obtained a copy of Administrator Certificate #6003054740 which is up to date with expiration date of 06/14/2023. At this time, LPA requested a current copy of liability insurance and LIC 610E- Emergency Disaster Plan to be emailed to LPA Yang by Friday November 4, 2022. There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Resident Services Director.the state’s words, verbatim · CDSS document, Oct 29, 2022

Allegation investigated: Resident sustained serious injuries due to a lack of care and supervision. Facility failed to seek timely medical attention

On 9/15/2022 at 9:45 AM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a complaint investiation visit. LPA met with administrator Cliff Keene and discussed the purpose of the visit was to deliver complaint finding regarding the allegations above. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. On 3/22/2022 at 2:59 PM, Resident 1 (R1) was found on the floor of R1’s apartment at The Inn at the Terraces, after sustaining an unwitnessed fall and was transported to the hospital. Medical records revealed R1 sustained a closed fracture of R1’s right distal femur (noted “as consequence of the fall”) and had an unstageable, full thickness pressure wound on R1’s right buttock. R1 sustained healing abrasion on R1’s right elbow and left forearm and a deep tissue injury on R1’s left heel. The Wound Care Registered Nurse (RN) assessed and found R1’s wounds to include the heeling properties/scabbing of the elbow and forearm abrasion consistent with wounds that are 1-2 days old. Cont'd on LIC 9099-C Substantiated This Department determined staff neglected R1 by failing to supervise R1 appropriately and failing to check on R1. Per facility key fob records, R1 was last seen in R1’s room on 3/20/2022 at 2:56 PM. Staff were unaware of R1’s whereabouts. Although a few staff stated they saw R1 on the morning of 3/22/2022, those statement did not match the key fob records for R1’s room door. There is a preponderance of evidence obtained, that R1 was last seen in R1’s room on 3/20/2022 at 2:56 PM and R1 never left the room until discovered on 3/22/2022 at 2:59 PM. R1 sustained an unwitnessed fall in R1’s room during this time period. R1 was discovered in R1’s room on 3/22/2022 at 2:59 PM when staff smelled “a really rancid urine smell” coming from the room of R1 which was what prompted staff to check on R1. Staff discovered R1 lying on the ground mostly nude and on R1’s left side. R1 was lying on a pool of urine described size as “a basketball or two.” Staff stated, “You could really smell it (urine). It was a lot.” R1 was “not fully aware” which is not R1’s baseline. At this time staff summoned for assistance to include 911. R1 was admitted to the hospital and diagnosed with a broken bone, pressure injuries and abrasions. Paramedics and medical staff (nurse and doctor) provided statements to support that the injuries were 1-2 days old. Blood work indicated R1 was incapacitated for at more than 8 hours which is evidence that R1 sustained the pressure injuries as a result of laying in a position for a prolonged period of time due to staff not checking on R1. Although staff stated they saw R1 the morning of 03/22/2022. Medical evidenced supports R1 was down for a prolonged period of time resulting in pressure wounds and abrasions, in addition to R1 sustaining a fractured femur as a result of R1’s fall. All staff interviewed, including facility Administrators admitted, although R1 was independent and did not need assistance for ADL’s, the facility policy was that every resident is checked on and accounted for at every meal. This is documented on the Resident Meal Checklist. The Resident Meal Checklist documents that R1 attended breakfast, lunch and dinner on 3/21/22, however, serving staff interviewed admitted that on occasion residents were checked off as receiving a meal that had not received a meal. It was documented that R1 did not receive breakfast or lunch on 3/22/2022 and was not checked on as per facility policy. Cont'd on LIC 9099C The preponderance of evidence supports that R1 did not receive timely medical attention due to staff neglecting to check on R1 when R1 missed Breakfast on 3/22/2022. Door key fob records obtained indicate that no one entered or exited Alice’s room after 03/20/2022 at 2:56 PM when R1 was last seen in her room. In an addition to the complaint allegations, additional deficiencies will be cited during a case management visit. Reference LIC 809 (Facility Evaluation Report). Based on observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 15, 2022 · control 25-AS-20220330164722

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Sep 16, 2022

87468.2 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 in privately operated residential care facilities for the elderly shall have all the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.This requirement is not met as evidenced by: Based upon interview, observation and documentation. The Licensee failed to ensure R1 was free from neglect. This poses and immediate health, safety and personal rights risk to Residents in carethe state’s words, verbatim · CDSS document, Sep 15, 2022

Plan of correction: Licensee agrees to improve upon the attendance check off for meals and submit to CCLD no later than 9/16/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 16, 2022

87464 Basic Services (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). This requirement is not met as evidenced by: Based upon interview, observation and documentation. The Licensee failed to ensure R1 was provided with care and supervision which resulted in serious injury. This poses and immediate health, safety and personal rights risk to Residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2022

Plan of correction: Licensee agrees to create a policy to incease follow up on assessments of residents. Policy will be provided to CCLD no later than 9/16/2022 Civil penalty assessed in the amount of $500

Type of visit: Case Management - Deficiencies

On 09/15/2022 at 930 AM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a case management related to a complaint investigation 25-AS-20220330164722. LPA met with Executive Director/Administrator Cliff Keene and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask During the course of complaint investigation 25-AS-20220330164722, in which there are substantiated allegations: Resident sustained serious injuries due to a lack of care and supervision and Staff neglected to seek timely medical attention for resident, additional deficiencies were discovered. During the course of the investigation, the Department found staff were falsifying information on the Resident Meal Checklist. Staff were checking off that residents had been in attendance during meals when they had not been. Due to falsifying the information on the resident meal checklist on 3/21/2022, a resident’s fall and injury went undetected. The facility’s policy was that residents who did not attend meals were to be checked on. The resident was not checked on when the resident did not attend meals on 3/21/2022. During interviews, staff indicated it was not clear who was responsible for checking on residents who did not show for meals. Staff indicated part of the confusion was related to being short staffed. On 7/13/2022 the Department learned that the facility had key fob records to the resident’s door. The facility discovered on 3/22/2022, that there was no indication per the key fob records, that the resident had exited their room. The facility was aware there was an open complaint investigation on 04/08/2022 and did not disclose they had key fob records that indicated the resident was not checked on for at least 24 hours. The following deficiencies were cited per Title 22 of the California Code of Regulation (809D). Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.the state’s words, verbatim · CDSS document, Sep 15, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Sep 16, 2022

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based upon interview, observation and document review the Licensee failed to ensure staff were accurately documenting the services provided to residents. The licensee did not volunteer key fob records but instead provided statements that were not supported by the key fob records. This poses an immediate Health, Safety and/or Personal Rights risk to clients in carethe state’s words, verbatim · CDSS document, Sep 15, 2022

Plan of correction: Licensee agrees to volunteer information that would be useful in an investigation. Licensee agrees to provide a letter stating this to CCLD no later than 9/16/2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR87205(a) · Plan of correction due date: Sep 16, 2022

87205, Accountability of Licensee Governing Body states-(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement is not met as evidenced by: Based upon interview, observation and document review the Licensee failed to provide adequate oversight of staff to ensure compliance with policies and the welfare of individuals policies were intended to serve. This poses an immediate Health, Safety and/or Personal Rights risk to clients in carethe state’s words, verbatim · CDSS document, Sep 15, 2022

Plan of correction: Licensee agrees to institute a better audit process for policies in place. Licensee agrees to provide improved upon audit process to CCLD no later than 9/16/2022

Type of visit: Case Management - Incident

On 2/24/2022 at 1:00PM Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a case management on two incident reports received related to falls, LPA met with Executive Director/Administrator Cliff Keene and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask LPA reviewed an incident report that detailed an incident that occurred on 1/8/2022. On this date a resident (R1) fell out of bed resulting in the need for medical attention. LPA discussed the residents diagnosis with Administrator. ONR (occupational therapy) assessed him for a change in condition. R1 has not had a fall since. LPA reviewed an incident report that detailed an incident that occurred on 1/10/2022. On this date a resident (R2) tripped on her own feet, falling and resulting in complaints of pain to shoulder and head. R2 refused to be transported by EMS. LPA discussed the incident with Administrator who stated the occupational therapist assessed R2 for change in condition and assessed R2 for fall risk. Administrator said since the incident R2 has not had another fall and is still receiving physical therapy. No deficiencies cited.the state’s words, verbatim · CDSS document, Feb 24, 2022

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA) Misty Valencia and Dawn Keane conducted an unannounced complaint investigation visit to deliver findings for the above allegation. LPA met with Cliff Keene, Administrator. Prior to initiating the complaint visit, LPA completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID related symptoms. LPA contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Additionally, LPA was assessed at the front desk. continued on 9099C Substantiated Unlawful eviction LPA interviewed Admin, RSD, residents, and reviewed records. During the investigation, it was determined that there was sufficient evidence to substantiate Resident was given an unlawful eviction. During the investigation, the Admin admitted this is true, but the notice is being rescinded and the facility did not follow through with the eviction. Based on the findings of this investigation LPA finds allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. LPA will not be citing for this substituted allegation due to the facility not following through with the eviction. Facility understands that this is a citable allegation and may be cited in the future for any unlawful evictions. No deficiencies are cited during today's visit. An exit interview was conducted with Administrator and copy of report was provided. Facility did not provide resident with activities that met residents needs Facility is not meeting the resident's needs as identified in the pre-admission appraisal During interviews with Administrators, staff, residents and records reviewed, it was determined that Facility did not provide resident with activities that met residents needs and facility is not meeting the resident's needs as identified in the pre-admission appraisal to be unsubstantiated. LPA interviewed Admin, RSD, residents, and reviewed records. During the investigation, it was determined through interviews with Admin, RSD, and six of six 6/6 residents, who all agreed that their needs are being met and they have no complaints. The preponderance of evidence standard has not been met. The allegations are unsubstantiated. This agency has investigated the above listed allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred therefore, we have found the allegations to be UNSUBSTANTIATED. No deficiencies are cited during today's visit. An exit interview was conducted with Administrator and copy of report was provided.the state’s words, verbatim · CDSS document, Nov 9, 2021 · control 25-AS-20210811142633

Type of visit: Required - 1 Year

10/06/2021 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Executive Director Cliff Keene and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask, gloves. Additionally, LPA Knight was screened by facility staff. LPA Knight and Mr. Keene toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident apartments common bathrooms, dining room, bistro, elevator and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight and Mr. Keene completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report was emailed to Cliff Keene.the state’s words, verbatim · CDSS document, Oct 6, 2021

Allegation investigated: Facility is not screening visitors.

Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegation; facility is not screening visitors and met with Wendy Anderson, Resident Services Director (RSD). Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was not screened by front desk clerk. continued on 9099C Substantiated During the investigation, it was determined that there was sufficient evidence to substantiate facility did not screen visitors. LPA reviewed sign in/out sheets for July 2, 2021, and July 7, 2021. LPA did not observe Visitor 1 (V1) sign in/out sheet and LPA was not screened on todays date July 08, 2021. On July 8, 2021 RSD failed to protect the personal rights of clients in care to receive safe and healthful accommodations to the health, welfare, and safety of the clients in care. Based on July 8, 2021 facility staff did not ensure visitors entering the facility are adhering to COVID-19 screening protocols according to PIN 21-17 page 3. Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the allegation is found to be Substantiated. California Code of Regulations (Title 22) is being cited on the attached LIC 9099D. Appeal rights are provided, and a closure interview was conducted.the state’s words, verbatim · CDSS document, Jul 8, 2021 · control 25-AS-20210707161727

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.19(a)(2) · Plan of correction due date: Jul 9, 2021

Personal Rights of Residents in All care Facilities... To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on LPA's visit and records reviewed front staff did not screen all visitors who entered the facility. This posed an immediate risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2021

Plan of correction: Licensee agrees to develop a plan that includes the importance of screening all visitors who enter the facility. Licensee will submit their plan for developing/training of such standards and include that training will be completed and proof submitted by 07/13/2021.