Non-compliance follow-up·November 29, 2022

Donna Gurriere, Licensing Program Analyst was in contact and met with Cliff Keene, Administrator. It was alleged that there was a Failure to meet personnel requirements and conduct inimical. LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility. Licensing Program Analyst (LPA) , Donna Gurriere met with Administrator, Cliff Keene, of Compass Rose, for a Case Management visit to follow up on a substantiated allegation of failure to meet personnel requirements and conduct inimical. continued On November 5, 2020, the Department concluded a Case Management investigation which alleged that the facility did not meet personnel requirements resulting in conduct inimical by a supervisor (S1) who allowed a caregiver (S2) with COVID-19 symptoms to work at the facility for multiple days while not fit for duty. It was alleged that S1 was contacted by S2 via text on July 22, 2020 with a temperature of 102.4 and S1 responded to S2 that S1 was “too tired to come in” and for S2 to re-take S2’s temperature after 20-23 minutes to see if there was a change. The subsequent temperatures were 102.4 and 101.9. After these temperatures were reported to S1, S1 no longer replied to S2’s communication attempts, so S2 finished the shift. S1 was aware that S2 had COVID-19 symptoms and allowed S2 to complete their shifts because S1 did not want to have to come into the facility after-hours and did not want to have to fill vacant shifts due to an illness. This decision by S1 created an unnecessary virus exposure to residents and other staff. The allegations were substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, 87411(f) for Personnel Requirements, and California Code of Regulations (CCR) Title 22, HSC 1560.50(3) for Conduct Inimical. On July 20, 2020, the facility did not ensure all personnel, including the Licensee and Administrator, were in good health and physically and mentally capable of performing assigned tasks. The facility did not respond to concerns that a staff person may have a health condition that would create a hazard to self, other staff members, or residents. Following this event, the facility experienced a COVID-19 outbreak. On July 22, 2020, there were two additional residents that tested positive for COVID-19. Another resident was diagnosed positive on July 31, 2020, and the last resident was diagnosed positive on August 20, 2020 (five staff members tested positive throughout that time). continued According to the Mayo Clinic, COVID-19, is a severe acute respiratory syndrome. The severity of COVID-19 can vary; however, one may experience fever, cough, tiredness, loss of taste or smell, shortness of breath, difficulty breathing, muscle aches, chills, sore throat, runny nose, headache, chest pain, pink eye, nausea, vomiting, diarrhea, and rash, amongst other symptoms. COVID-19 may cause worsened symptoms such as pneumonia and people who are older have a higher risk of serious illness from COVID-19. Additionally, people who have an existing medical condition may have a higher risk of serious illness when infected with COVID-19. During the investigation, staff interviews conducted on October 29, 2020, October 30, 2020, and November 5, 2020, revealed that S2 communicated their symptoms to several other staff in addition to S1. On July 22, 2020, S2 communicated symptoms via phone call and text message to S1; but was not sent home and completed their shift. On July 23, 2020, S2 reported a fever via telephone and S2 came in for their shift and was sent home by a staff member other than S1. On July 24, 2020, S2 came to work with a 102.4 fever and S1 required re-testing of S2’s temperature but did not relieve S2 of work duties. On July 25, 2020, S2 called in sick, again due to ongoing COVID-19 symptoms. On July 26, 2020, S2 came to work and was subsequently sent home sick. On July 27, 2020, S2 was tested for COVID-19 and on July 28, 2020, S2 received positive COVID-19 test results. Based on medical records, interviews, and facility record review; the facility did not ensure personnel requirements were met to prevent inimical conduct on July 20, 2020, by employing a person in a supervisory position that did not practice proper infection control measures to reduce the spread of COVID-19. All facility staff and residents were exposed to an unnecessary risk of COVID-19. At the time of the complaint visit, on 11/05/20, the licensee was informed that a civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49. Today, 11/29/22 the Department is issuing a Civil Penalty per Health and Safety code section 1569.49 in the amount of $10,000. A copy of the LIC 421D was given to Cliff Keene and originals were signed. Exit interview conducted. Appeal Rights provided. A copy of the report issued. Cliff Keene's signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.