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Inspection visit

Follow-up on corrections

MAMA ANGELINA COCONOCHOLicense 3318809806 citations on this visit
6 citations recorded

Inspector’s narrative

What the inspector wrote

On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #18-AS-20220715115207. During today's inspection, LPA Colvin observed the following deficiencies, which was reviewed with Administrator Maria Gonzalez: Care of Persons with Dementia - LPA Colvin observed while at the facility that the auditory alarms on the front door and back door of the facility were switched to the "off" position, and were not alerting staff as to when the door was opened. The facility retains residents with Dementia, including resident (R1) who recently eloped from the facility on 7/4/22. Deficiency cited. Additionally, LPA Colvin observed that R1, who is diagnosed with Dementia, does not have a Physician's Report dated any more recently than June of 2021. The facility is required to have these reports updated at least annually for persons with Dementia. Deficiency cited. Fire Safety - While LPA Colvin was inspecting the front door alarm, LPA Colvin observed that staff had locked the front door using the deadbolt, which was only able to be unlocked from the inside of the facility with a key. This is an dangerous fire hazard to the residents and staff, as in the event of an emergency, they would not be able to quickly exit the front door unless they had the key on hand. Deficiency cited. Fire safety violations result in an immediate civil penalty in the amount of $500. Visitor Policy - When LPA Colvin walked up to the facility's front door from the outside, LPA Colvin observed a posted Visitation Policy/Hours, which limited visitation to 9:30am - 5:30pm on Monday - Friday, and 10am - 4pm on the weekends. LPA Colvin did observe an addendum to the hours underneath, which read that these hours could be flexible for family members . This is a violation of resident's rights to visitors, as the hours listed during the week are common working/business hours, and the hours on the weekend are even more severely restricted. Deficiency cited. Reporting Requirements - LPA Colvin observed through review of records (prior to today's inspection back at Community Care Licensing Regional Office that the facility has not submitted any Special Incident Reports (SIRs) since obtaining their License, and only submits Death Reports. The Licensee is required to submit an SIR for any event which poses a risk to residents' health or safety, including elopements from the facility. R1 eloped from the facility on 7/4/22 and was subsequently put on a psychiatric hold (51/50) at the hospital, neither of which were reported to Licensing by the facility. Deficiency cited. Personal Accommodations - While LPA Colvin was examining R1's bedroom, LPA Colvin attempted to turn on a light in order to see better. LPA Colvin observed that nothing happened when flipping the light switch, so LPA Colvin looked around and found a small lamp on a bedside table. LPA Colvin picked up the lamp to examine how to turn it on, and observed that it was not plugged in to anything. LPA Colvin still attempted to turn the light on (in case of batteries) but observed that nothing happened. There is no light available for use in R1's bedroom. Deficiency cited. Based on observations and record review conducted by LPA Colvin, the facility was cited and deficiencies noted on the LIC 809D pages. LPA Colvin conducted an exit interview wit Administrator Maria Gonzalez where a copy of this report, LIC 809Ds, LIC 421IM, and appeal rights were provided.

Citations

6 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87203Type A

    Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation with at least one area of the facility. LPA Colvin observed that the front door was locked with a deadbolt that is only able to be unlocked with a key. This is an immediate safety risk to residents in care.

  • 87211(a)(1)(D)Type A

    Reporting Requirements: (a) Each licensee shall furnish...reports...including... the following: (1) A written report shall be submitted ...within seven days of...(D) Any incident which threatens the welfare, safety or health of any resident, such as... unexplained absence of any resident. This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one occurance. LPA Colvin confirmed that no report was submitted for R1's elopment from the facility on 7/4/22. This is an immediate safety risk of all residents, as the facility has never submitted a report to Licensing.

  • 87307(a)(3)(B)Type B

    Personal Accommodations and Services: (a) Living accommodations...shall be related to the facility's function...The following provisions shall apply: (3) Equipment and supplies necessary...licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident...a lamp, or lights sufficient for reading... This requirement was not met by: Based on observation, the License did not comply with the above regulation with one resident. LPA Colvin observed no operational light source in R1's room other than the bedroom window. This is a potential personal rights violation of R1.

  • 87468.1(a)(11)Type B

    Personal Rights of Residents in All Facilities: (a) Residents...have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours... This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation. LPA Colvin observed Visitor Hours posted outside the facility which were unreasonably restrictive. Additionally, the posted hours are not what is reflected in the facility's Admissions Agreement. This is a potential personal rights violation of all residents.

  • 87705(c)(5)Type B

    Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least on resident. LPA Colvin observed that R1's most recent Physician's Report is dated 6/11/21. R1 is diagnosed with Dementia. This is a potential health and safety risk to R1.

  • 87705(j)Type A

    Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on observation, the Licensee did not comply with the above regulation with two exit doors. LPA Colvin observed both the front door and back door of the facility to have their auditory alarms turned off. LPA Colvin also tested the doors to confirm. This is an immediate safety risk to Dementia residents.

FAQ · About this visit

Common questions about this visit

What happened during the July 22, 2022 inspection of MAMA ANGELINA COCONOCHO?

This was a other inspection of MAMA ANGELINA COCONOCHO on July 22, 2022. 6 citations were issued: 3 Type A (serious) and 3 Type B.

Were any citations issued to MAMA ANGELINA COCONOCHO on July 22, 2022?

Yes, 6 citations were issued (3 Type A, 3 Type B). The first citation was for: "Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.