Whitten Heights Assisted Living and Memory Care

Allegation investigated: Resident has caused harm to other residents while in care

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations via tele-visit due to COVID-19 and for precautionary measures. LPA met with Administrator (AD) Carol Lee and explained the reason for today’s inspection. The investigation into the allegation that a resident has caused harm to other residents while in care revealed the following: During the course of the investigation, LPA conducted an on-site inspection on 03/24/21, inspected the facility, interviewed residents and staff, and obtained and reviewed copies of facility records. Interviews with AD, residents, staff, and review of documents revealed that Resident #1 (R1) physically attacked four (4) residents prior to 03/24/21. The first resident sustained a cut, was bleeding, went to the hospital, then came back the same day. Substantiated The second resident suffered a small cut, refused the hospital, and received first aid at the facility. The third resident suffered a headache but refused the hospital. The fourth resident was not injured. AD also reported that on 05/04/21 R1 punched a staff member in the jaw resulting in jaw pain and that on 08/30/21 R1 was in an altercation with a resident which resulted in scratches to both residents. In response to these incidents, the facility attempted verbal redirection of R1 and obtaining a new medical assessment, which R1 refused. However, these measures have not been effective, and thus the facility has not protected residents from harm. In addition, interviews with AD and review of documents revealed that the facility did not reappraise R1’s care needs for two (2) years despite R1’s change of condition and increased aggression which began in late 2019, and in any event was not providing adequate care and supervision to R1 as evidenced by R1’s attacks on other residents and the injuries R1 also sustained in some altercations. Thus, the allegation that a resident has caused harm to other residents while in care is substantiated. During the course of the investigation, CCLD obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Facility representative via tele-visit. This report will be emailed and an electronic email read receipt confirms receipt of the report. Facility representative agrees to send a signed copy by email. The second resident suffered a small cut, refused the hospital, and received first aid at the facility. The third resident suffered a headache but refused the hospital. The fourth resident was not injured. On 08/30/21, R1 was in an altercation with a resident which resulted in scratches to both residents and both received first aid. Based on interviews and documents, the facility provided timely medical attention in these instances, either by taking the resident to the hospital, offering to take the resident to the hospital, and/or providing first aid at the facility. Interviews with affected residents corroborated their satisfaction with the medical care they were offered or received. Thus, the allegation that Staff did not seek timely medical attention for a resident is deemed to be unfounded. The Department has investigated the above allegation and found it to be unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted with Facility representative via tele-visit. This report will be emailed and an electronic email read receipt confirms receipt of the report. Facility representative agrees to send a signed copy by email.the state’s words, verbatim · CDSS document, Oct 6, 2021 · control 22-AS-20210316113905

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 7, 2021

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on interviews and documents, the facility did not provide R1 the care and supervision they required as evidenced by R1’s multiple attacks on residents/staff and the injuries R1 also sustained in some altercations, which poses an immediate safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 6, 2021

Plan of correction: Licensee states that R1 is being relocated to a facility that can meet R1’s needs on 10/7/21. Licensee states they will submit proof and details of relocation to LPA by 10/8/21. Licensee states that if R1 has not been relocated by 10/15/21, Licensee will immediately begin the process to evict and relocate R1 to a facility that can meet R1’s needs and submit a status update to LPA by 10/22/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Oct 7, 2021

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. … This requirement was not met as evidenced by: Based on interviews and documents, the facility did not reappraise R1’s care needs for two (2) years despite R1’s change of condition and increased aggression which began in late 2019, which poses an immediate safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 6, 2021

Plan of correction: Licensee previously provided updated reassessments for R1 to LPA.

Allegation investigated: Facility floors are in disrepair and present a fall hazard Facility is unsanitary

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Carol Lee and explained the reason for today’s inspection. The investigation into allegations that Facility floors are in disrepair and present a fall hazard and Facility is unsanitary revealed the following: During the course of the investigation, LPA conducted an on-site inspection on 07/20/21, inspected the facility, interviewed residents and staff, and obtained and reviewed copies of facility records. LPA’s interview with AD revealed the carpets have not been replaced in approximately 10 years. On 07/20/21, LPA and AD observed torn carpets, holes in carpets, carpets separating and leaving gaps, and carpets folding into small mounds on all three floors creating a minor fall hazard. Thus, the allegation that the facility floors are in disrepair and present a fall hazard is substantiated. There was no smell of cigarette smoke noted inside the facility during this inspection. Substantiated However, LPA and AD observed carpets with extensive staining and possible mold on all three floors, especially in the dining room and in the entry ways of rooms. Thus, the allegation that the facility is unsanitary is substantiated. An immediate civil penalty is being assessed in the amount of $250 for a repeat violation of the same citation previously issued on 10/07/20. The civil penalty shall be assessed until the violation is corrected. During the course of the investigation, CCLD obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Based on review of the facility's compliance history, which revealed the licensee was cited for the same violations within the last 12 months, civil penalties in the amount of $250 per repeat violation are being assessed. Civil penalties of $100 per day, per violation will accrue until the deficiencies are corrected. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. LPA reviewed pest control invoice dated 07/14/21 showing the pest control company came to address the issue. The pest control issue was an isolated incident and the facility took adequate measures to address the issue and thus the allegation that the facility is infested with pests is unfounded. The Department has investigated the above allegation and found it to be unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Sep 15, 2021 · control 22-AS-20210714082316

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Oct 13, 2021

87307 Personal Accommodations and Services: … (d) …: (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 evidenced by: Based on observation, the licensee did not ensure carpets were free from fall hazards including tears, holes, gaps, and mounds on all 3 floors, which poses a potential health safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2021

Plan of correction: Licensee states they will submit photographs of affected carpets to LPA by COB tomorrow, repair or replace the affected carpets, and submit photographic proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 13, 2021

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by: Based on observation, the licensee did not ensure carpets were free from stains and possible mold on all 3 floors, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2021

Plan of correction: Licensee states they will submit photographs of affected carpets to LPA by COB tomorrow, repair or replace the affected carpets, and submit photographic proof to LPA by POC due date.