Follow-up on corrections·November 27, 2024

Licensing Program Analysts (LPAs) Pang Lee and Arielle Pascua arrived at this facility unannounced on 11/27/2024 to conduct a case management visit. LPAs met with direct care staff Jemesa Aisake and explained the purpose of the visit. The purpose of this visit is to amend visit report dated on 11/21/2024 to generate LIC 809-D and civil penalty. The census is 9. Based on records review it was learned that resident 1 (R1) was admitted to the facility on 11/09/2023. According to R1’s LIC 625 Appraisal/Needs and Service Plan, there was no indication that R1 required assistance with feeding. However, based on an LIC 624 incident report dated 05/22/2024, R1 was admitted to Methodist Hospital of Sacramento after care staff observed R1 coughing profusely during a meal. The coughing persisted even as staff assisted with feeding. The Methodist Hospital Emergency Documentation recommended that R1 be placed on a soft, bite-sized diet with thin liquids. However, the facility did not update R1’s LIC 625 Appraisal/Needs and Service Plan to reflect this recommendation. The interviews with care staff, revealed staff were aware of R1’s dietary needs, including the need for food to be cut into small pieces, as well as R1’s tendency to eat too quickly. Despite this, the facility did not update R1’s LIC 625 Needs and Service Plan and Reappraisals to reflect these changes. The facility administrator did not report the changes to R1’s physicians so that the physician’s report could also be updated. Additionally, R1 was accepted into and retained at the home, where R1 require assistance with all activities of daily living, as outlined in R1's LIC 625 Needs and Service Plan and confirmed during an interview with Administrator Cleopatra Gardiner and direct care staff Jemesa Aisake. Furthermore, there were no exceptions made for R1, as R1 is not receiving hospice care. On 11/21/2024, LPA Lee observed a volunteer staff (VS) present in the facility. It was observed that VS w as assisting with sweeping, changing residents’ sheets, socializing with the residents, and shadowing the caregivers. Based on records review VS is does not have a California clearance and is not associated to the facility. On 11/21/2021, LPA Lee also delivered an Order to Licensee/Facility of Immediate Exclusion and explained that staff (S1) is excluded from any involvement in the facility effective immediately. The following deficiency were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this LIC 809 report, exclusion letter and appeal rights were given to the facility.