Non-compliance follow-up·August 1, 2023

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management / Non-Compliance visit today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. The LPA met with Terri Weitzman and explained the reason for the visit. The last legal/non-compliance visit was conducted on 05/22/2023. The LPA and Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature. Fire extinguishers were charged and last serviced within the past twelve (12) months. Planned activities are offered. Activity rooms and common spaces appeared clean and in good repair. The facility has several enclosed courtyards with appropriate outdoor seating for resident use. The swimming pool on the premises was observed to be locked. RESIDENT ROOMS: The LPA and Executive Director observed eight (8) rooms, and rooms were furnished with clean linens, furnishings and lighting. Restrooms were observed with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. At 12:34 p.m., the LPA observed a basket of personal care items and razors in Room 53. At 12:40 p.m., personal care items were in Room 67. At 12:47 p.m., personal care items were observed in Room 17. FILES: From 12:45 p.m. – 1:10 p.m., the LPA reviewed the files of the three (3) resident that had personal care and hygiene items accessible in their rooms. Out of the three (3) files reviewed, the LPA reviewed physician’s reports and identified that there was one (1) resident (Resident #1 – R1) that was deemed at risk if they have access to personal care items. All three residents had a diagnosis of Dementia. CONT 809-C MEDICATION AUDIT: From 1:20 p.m. – 2:10 p.m., a medication audit was conducted for three (3) residents. The following was noted: - Resident #2 had an as-needed (PRN) medication for acetaminophen that was administered two (2) times; however, staff only documented that R2 was assisted with the self-administration of this PRN medication one (1) time. - Resident #3 had a PRN medication for acetaminophen that was administered seven (7) times since August 2022; however, there was no documentation to confirm the dates and times that R3 was assisted with the self-administration of this as-needed medication. INCIDENT REPORTS: The LPA reviewed incident reports pertaining to Resident #4 (R4). On 06/01/2023 and 7/2/2023, R4 left the facility unassisted. During the 06/01/2023 incident, R4 was noted outdoors outside the community back patio, behind the fence, sitting on a hill. R4 was escorted back into the facility without any notable injuries. During the 7/2/2023 incident, staff noted that a window was broken in a resident room. After completing a resident count, staff observed that R4 was not in the community. Staff canvassed the surrounding areas and R4 was located by the Administrator. R4 was noted to have skin tears. Emergency services were called and R4 was hospitalized. After this incident, an in-service training on Elopement Protocols and Procedures was held. R4’s physician’s report confirmed that R4 is not able to leave the facility unassisted. On two separate occasions, R4 was able to leave the facility, unbeknownst to staff. R4 is currently out of the facility at this time due to a medical-related issue. LEGAL: On 6/29/2023, licensee has requested a reduction in the frequency of calls with CareerSmart. Per the stipulation, the licensee must have weekly calls with CareerSmart. Licensee is requesting for weekly calls to take place either bi-weekly or once a month. Approval from the Department is pending at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued via email. Signatures were obtained.