Yorkshire Village

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility staff with LPA identification and business card. LPA was able to complete one (1) domain, due to time constraint, LPA will need to return to complete the Annual Inspection. LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative at the time of the exit interview.the state’s words, verbatim · CDSS document, May 22, 2024

Allegation investigated: Staff did not notify responsible party of change of resident's health condition.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Teresa Mapilis, and informed her of the purpose for her visit. A report was received by the Department alleging the facility did not notify family members of residents currently experiencing rashes. On this visit the LPA conducted staff and resident interviews, reviewed records and obtained copies of pertinent documentation. Nine resident interviews were conducted; of the nine, four residents reported they currently had a rash on their body. According to Administrator, Teresa Mapilis, there about seven residents in building B who currently have a rash. One third party interview revealed the responsible party of Resident One (R1) was not notified of the resident's rash. An interview with Administrator Mapilis revealed the responsible party of R1 was not notified by the facility due to the resident receiving services from a hospice agency. Administrator Mapilis reported the hospice agency would have reached out to R1's responsible party to notify them of the health condition. Therefore, based on interviews, this allegation Substantiated is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. This violation poses a potential threat to the health, safety, and personal rights of residents in care. A citation will be issued. An exit interview was conducted with Business Office Manager (BOM), Nicole Anguiano. This report was reviewed, and a copy was provided, along with the LIC 811, and instructions on appeal rights.the state’s words, verbatim · CDSS document, Apr 22, 2024 · control 18-AS-20240417082812

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Apr 29, 2024

Personal Rights of Residents in All Facilities: (a) Residents in all RCFEs shall have all of the following...rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services...This requirement was not met, as evidenced by: Based on interviews, the licensee did not ensure R1's right to have their representative informed of activities related to care was met. Admin. revealed the responsible party of R1 wasn't notified due to R1 receiving services from a hospice agency, who would have reached out to the responsible party for notification.the state’s words, verbatim · CDSS document, Apr 22, 2024

Plan of correction: The Administrator stated in-service training will be provided to staff regarding notifying family members of hospice residents of any health changes.

Allegation investigated: Staff did not ensure facility is kept free of bed bugs.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Teresa Mapilis, and informed her of the purpose for her visit. A report was received by the Department alleging there are residents in care who have rashes, all over their bodies, which appear to be bed bug bites for which the facility has not provided treatment. On this visit the LPA conducted staff and resident interviews, reviewed records and obtained copies of pertinent documentation. Nine resident interviews were conducted; of the nine, four residents reported they currently had a rash on their body. One of the four residents reported the facility is treating the rash; another resident reported the facility was not treating the rash; and the remaining two residents could not provide any information on whether their rash was being treated. According to Administrator, Teresa Mapilis, there are about seven residents in building B who currently have a rash. She reported there is only one resident, Resident Two (R2) who has been Unfounded diagnosed with an infectious condition. According to the Administrator, infection control policies are being followed for R2, including environmental cleaning and frequent showers. Staff interviews confirmed environmental cleaning and frequent showers are being completed. Documentation, including medical records and discharge paperwork, revealed the remaining residents have not been diagnosed with the contagious disease and are currently receiving treatment for the rash they were diagnosed with. Additionally, an Attendance Log revealed care staff were provided with training relating to skin issues on 04/18/2024. No information was received to indicate there is a bed bug infestation at the facility. Therefore, based on interviews and records, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Business Office Manager (BOM), Nicole Anguiano. This report was reviewed, and a copy was provided, along with the LIC 811.the state’s words, verbatim · CDSS document, Apr 22, 2024 · control 18-AS-20240417082812

Allegation investigated: Resident was physically assaulted by another resident which resulted in injuries due to lack of supervision.

Licensing Program Analyst (LPA), Jacqueline Shaw Ross made an unannounced visit to deliver findings for the allegations noted above. LPA met with Nicole Anguiano, Business Office Manager, and explained the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews, and records review. On 1/5/2024, Community Care Licensing received an allegation that a resident was physically assaulted by another resident that resulted in injuries. It was reported that R2 became agitated with R1 over a comment that was made by R1. R2 began yelling at R1 and grabbed R1's left arm, leaving a bruise. R1 called the police, and police arrived however no charges were filed. LPA interviewed staff who corroborated that the incident did occur. The assault was witnessed by a newly hired staff member who was taking a video training course. LPA interviewed R1 who stated there was concern there was not enough supervision which led to the assault. Substantiated Staff indicated no other staff were around during the assault except for the newly hired staff member. LPA interviewed R2 but was unable to finish the interview due to R2 became verbally aggressive to LPA. LPA reviewed documents pertinent to the investigation that included facility incident reports, client records and photos of the injury. Based on LPA’s observations, interviews conducted, and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with Appeal Rights. Based on LPA’s observation, interview(s) conducted and record review(s), the preponderance of evidence shows that the allegations is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, a copy of this report, appeal rights was provided to Nicole Anguiano, Business Office Manager.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 18-AS-20240105081727

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(A) · Plan of correction due date: Mar 22, 2024

87411 Personnel Requirements- General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure facility personnel to be sufficient in numbers and competent to provide the services necessary to meet resident needs.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: Facility agrees to revisit the schedule for the assisted living building that may include increasing more staff or have more frequent checks to ensure there is consistent supervision, as well as provide additional training on supervision and safety of residents. Facility will provide training log and revised staffing schedule to the Department by POC date of 3/22/2024.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced to the facility to conduct additional interviews with witnesses regarding complaint 18-AS-20240105081727. LPA was granted entry into the facility and met with Executive Director Teresa Mapilis. LPA explained the purpose of the visit. LPA was informed that the additional staff witness was scheduled to begin work at 2:00pm but called out due to a family emergency. LPA conducted an interview with Executive Director and documented the information on a LIC 812. No additional interviews were conducted. A copy of this document was provided to Executive Director Teresa Mapilis.the state’s words, verbatim · CDSS document, Jan 9, 2024

Allegation investigated: Residents are left in soiled diapers for an extended period of time

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to the facility to initiate a complaint investigation into the above allegation. LPA identified himself and met with Wellness Director Emma Andrade and discussed the purpose of the visit. The investigation consisted of interviews with staff, residents and records review. Administrator, Theresa Mapilis was in the facility. LPA toured the facility, and interviewed 8 residents, (R1, R2, R3, R4, R5, R6, R7, R8), and 3 staff members (S1, S2, S3, S4, S5). LPA reviewed documentation in relation to the allegation and received copies. Continued on LIC9099-C. Unsubstantiated Regarding the allegation, "Residents are left in soiled diapers for an extended period of time". Through review of documentation, and interviews conducted with residents and staff, issues related to residents not being regularly changed related to incontinence was found to not occur. LPA also decided that due to the lack of evidence to corroborate the allegation, the allegation was deemed to be UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that 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. An exit interview was conducted and a copy of this report was discussed with and provided to Ms. Mapilis along with copies of the LIC9099-C, and LIC811.the state’s words, verbatim · CDSS document, Jun 30, 2022 · control 18-AS-20220622082401

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and met with Executive Director Teresa Mapillis, who was informed of the purpose of the visit. At the time of visit there was 11 staff and 76 residents present. The facility currently has zero positive or suspected Covid-19 cases. During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility and a single entry point for each building (A, B, C, and D) was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all inspected shower rooms and resident restrooms. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There is a plan in place to isolation residents and monitor those in isolation. LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a plan in place to clean and disinfect the highly touched surfaces. LPA reviewed the Guardian roster and observed 4 staff (S1, S2, S3, and S4) who had fingerprints "in process". S4 passed away and is no longer working at the facility. LPA called the regional office and checked fingerprint status for all 4 employees and was informed that all 4 staff had been associated to the facility Yorkshire Village (331800223). There were no deficiencies noted at the time of the visit. An exit interview was conducted, and a copy of this report was reviewed and provided to facility Executive Director, Teresa Mapillis.the state’s words, verbatim · CDSS document, May 24, 2022

Allegation investigated: Resident is not being allowed to have visitors.

Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced to investigate the above allegation. LPA identified himself and discussed the purpose of the visit with Administrator Teresa Mapilis. Through the confirmation of the allegation with the RP, interview with Client one (C1) and interview with the Administrator, it was determined that C1 had not been allowed a visitor per Title 22 Section 6 Chapter 8 Article 9 Resident Records 87468.1(a)11 Personal Rights of Residents in All Facilities. Thus, this allegation was deemed 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. An exit interview was conducted with Administrator Mapilis and a copy of this report, PIN 21-48-ASC, along with LIC9099-D, LIC 811, and Appeal Rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Dec 14, 2021 · control 18-AS-20211208140316

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Dec 28, 2021

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:(11) To have their visitors....permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not being met as evidenced by: Based on interviews obtained, it was determined that this poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 14, 2021

Plan of correction: Licensee to self certify that they have reviewed the regulation, and send LPA an email detailing completion by 12/28/21.

Allegation investigated: Staff overmedicated resident. Staff made resident dance for food.

Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced to investigate the above allegations. LPA identified himself and discussed the purpose of the visit with Business Office Manager Nicole Anguiano and toured the facility. It was alleged that Resident #1 (R1) left Yorkshire Village on November 4, 2021 because R1 felt they were being mistreated by the staff by having R1 take more medication than R1 should and making R1 dance for food. This investigation consisted of record review, and interviews with relevant parties. Through interviews with R1 and staff, LPA determined that R1 was not given or made to consume more medication that was ordered. Additionally, a record review of R1’s Medication Administration Record (MAR) indicated that R1 was receiving medication as ordered by their physician. Thus, this allegation was deemed to be UNSUBSTANTIATED. Based on evidence obtained during today’s visit, LPA has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was provided. This is an amended version of the original report dated December 7, 2021. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 7, 2021 · control 18-AS-20211201093042

Allegation investigated: Resident was left on the floor for an extended period of time Resident fell and sustained an injury

On 10/21/21 LPA Cuevas conducted an unannounced visit to the facility to follow up with complaint, control #18-AS-20200221104723.LPA was greeted by Executive Director, Teresa Mapilis who was informed of the purpose of visit. During the investigation LPA Cuevas conducted: facility file review, resident record review, staff interviews, observations, and review of pertinent documents. Allegation #1: Resident was left on the floor for an extended period. Based on interviews conducted and documents reviewed by LPA, it was determined that that the evening of February 18, 2020 resident #1 (R1) was sent to Hospital as a result of staff observing R1 to be pale in appearance and not responding to their communication. Per staff statements and available records no falls were reported for R1 on 2/18/20. Furthermore, interviews provided suggest that R1's reason for being transported to hospital was a result of change of condition not unfitness fall. Unsubstantiated Based on available information, there is not enough preponderance of evidence to determine that R1 was left in the floor for a long period of time, as such allegation is being UNSUBSTANTIATED, a findings that the allegation is UNSUBSTANTIATED means that that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the allegation occurred. Allegation #2: Resident fell and sustained an injury Based on interviews conducted and documents reviewed by LPA no falls were reported for R1 on 2/18/20 the day of hospitalization. Furthermore, interviews communicated that R1, who was wheelchair bound had exiting bruising and scrapes in both knees and hands prior to being sent out to hospital. Staff reports that scrapes and bruises were due to R1's constant banging on objects as a form of communication. Additionally, staff reports R1 to be tall in stature and to have had knees scraped and bruised as a result of R1 hitting his knees in the dining room table, when being agitated or anxious. Per staff, when such actions were observed first aid would be applied and behavioral interventions provided. Based on available information, there is not enough preponderance of evidence to determine that R1 fell and sustained an injury, as such allegation is being UNSUBSTANTIATED, a findings that the allegation is UNSUBSTANTIATED means that that although the allegation allegation occurred..may have happened or is valid, there is not a preponderance of the evidence to prove that the An exit interview was conducted with Executive Director, Teresa Mapilis were this report was reviewed and provided.the state’s words, verbatim · CDSS document, Oct 21, 2021 · control 18-AS-20200221104723

Allegation investigated: Staff not allowing resident to leave facility.

Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to initiate a complaint investigation into the above allegation. LPA identified herself and met with Administrator, Theresa Mapilis, and discussed the purpose of the visit. The investigation consisted of interviews with staff and residents and records review. LPA interviewed Resident #1 (R1) who stated that they have not attempted to leave the facility grounds due to not having anywhere to go or having a car. R1 stated that they are able to leave the facility; however, R1 has no finances or a place to go. R1 stated that they have a Public Guardian who placed R1 at the facility and handles R1's finances. LPA interviewed Resident #2 (R2) who stated that they are able to come and go as they please. LPA interviewed Staff #1 (S1) and Staff #2 (S2) who denied that staff is not allowing residents to leave the facility. S1 and S2 stated that they are accommodating to R1's request to leave the facility to go to the store. S1 and S2 denied that R1 has been attempting to leave the facility but rather requesting to live more independently. Due to R1's interview and lack of evidence to corroborate the allegation, the allegation is Unsubstantiated unsubstantiated. Based on evidence obtained during today’s visit, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning that 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. An exit interview was conducted where this report was discussed and a copy was provided to Mapilis.the state’s words, verbatim · CDSS document, Jul 15, 2021 · control 18-AS-20210709103434