complaint·November 26, 2024

Interviews conducted with residents revealed 3 out of 6 residents stated staff have been seen wearing gloves and mask while providing care. 2 out of 6 residents stated staff were sometimes not wearing proper PPE when providing care. 1 out of 6 residents stated to not be aware of breakout. Interviews with staff revealed staff were informed of symptomatic residents on 11/18/24 and staff implemented wearing PPE, resident isolation, and were provided training. On 11/20/24 a server was observed providing meals in residents rooms without changing gloves in between residents during a visit provided by PDPH. On 11/22/24 staff was observed not implementing proper hand hygiene procedures per PDPH. Training was provided to staff on 11/17/24 on Infection control, and on 11/22/24 training was provided on disinfecting, PPE proper use, and hand hygiene. Although the residents and staff stated to have been following guidance to prevent the spread. Visits conducted by PDPH revealed staff did not follow hand washing and glove changing guidance. Therefore, allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Regarding allegation: Staff are not following infection control requirements. It is alleged facility staff enter a resident’s room with infections disease symptoms and did not use proper Personal Protective Equipment (PPE). On 11/19/24 emergency personnel responded to a call upon entering a resident’s room with symptoms of infectious disease facility staff assisting did not put on proper PPE prior entering the room. Interviews conducted with residents revealed the following 3 out of 6 residents stated staff used proper PPE when entering the rooms to provide care. 3 out of 6 residents either did not observe or remembered whether staff used proper PPE supplies. Interviews with staff revealed staff were provided PPE supplies which were placed outside residents’ rooms that were in isolation. However, staff admitted that during the visit of emergency responder, staff was not wearing PPE when assisting resident with infectious disease symptoms going out to the hospital. During facility’s tour, LPA observed PPE supplies in 3 rooms who are currently in isolation. One staff was observed going into a resident’s room to provide care with face mask under the chin as staff walked to provide care into resident’s room. Although facility has implemented guidelines and provided training to staff, staff did not follow infection control guidance. Therefore, this allegation is substantiated. (CONTINUED ON LIC 9099C) Based on LPAs observations, 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 . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, and appeal rights were provided. Facility reported outbreak to Community Care Licensing (CCLD) on 11/17/24 and to PDPH on 11/18/24. Families, residents, and staff were notified of outbreak on 11/18/24 via letter. On 11/19/24 facility personnel responded to a call at the facility. Staff in charge did not notify personnel of outbreak. Although the facility staff did not informed emergency personnel regarding outbreak at the facility. Facility administration notified CCLD and PDPH within 24 hours of the third resident with symptoms. Regulation stated an outbreak must be notify to CCLD and PDPH. 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 . Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.