Follow-up on corrections·September 12, 2024

On 9/12/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver, Princess Allen . LPA spoke with Darius Stir by phone and reviewed the report contents. On 9/3/24 the department received a death notification for R1. As R1's passing was unexpected, the department conducted a case management visit, on 9/10/24, to gather additional information. LPA received resident records, interviewed 2 caregivers and the Administrator. LPA received contact phone numbers in order to conduct additional interviews. LPA reviewed R1's medications. During the 9/10/24 visit, staff interviewed could not provide details about how long R1 had been declining, loss of weight nor decreased oral intake. Interview with Administrator described R1 had significantly declined to the extent that Administrator was seeking to establish a new primary care physician with the intent to initiate hospice care services. Administrator also stated that written records were not kept of R1’s decline and records found that R1 had not had regular/ required physician evaluations since 2021 to 8/30/24. R1 had a diagnosis of Dementia. Lastly, the medication review and interview with Administrator found that R1 had their medications refilled on 8/26/24 yet Administrator held all of R1's medications , 8/26/24- 8/31/24, because Administrator was concerned about possible adverse effects given R1’s condition. There was not medication hold issued by a physician. On 9/10/24, Administrator also stated that they have been operating the home for the licensee and in doing so, are currently leasing the home from the licensee. LPA directed the Administrator to discontinue the lease so that the licensee reestablishes control of property. Report continued On 9/12/24, LPA conducted follow- up interviews with the following: A Southern CA tele-health service who wrote an LIC 602 physician’s report dated 8/30/24 for R1- a physician’s assistant (PA) conducted the phone evaluation. R1 was unable to participate in the evaluation due to dementia. Height, weight and blood pressure were not assessed. The facility does not have a waiver in place for a non-physician medical profession to conduct and sign the evaluation. An area health care provider was contacted by Administrator on 8/28/24 to enroll R1 and to establish Hospice Serviced. Hospice services were approved to begin 9/4/24. The provider provided a death certificate that listed: immediate cause of death as (A) advanced dementia, Parkinson’s disease- onset 10 years; underlying cause of A- poor oral intake with a time for “6 mo”; weight loss – “3 m”; and failure to thrive “1 mo”. LPA contacted a family member contact- R1’s family member described R1’s passing as sudden but not unexpected as R1 had been declining since a 2021 hospitalization. Described the care at the facility as very good- R1 gained weight after admission as R1’s food intake had increased at the home. Family had not seen R1 in “many months”. Family was not informed of R1’s recent decline. Family was notified of R1’s passing by the coroner on 8/31/24. These findings demonstrate that Administrator, Darius Stir, did not fulfill the duties and responsibilities of administrator, while Samantha Shaw was absent, when Darius Stir did not demonstrate knowledge of the requirements for providing care and supervision appropriate to the residents; nor did he demonstrate knowledge of and ability to conform to the applicable laws, rules and regulations. Report continued Since the LPA visit of 9/10/24, three residents have been sent for medical care. Administrator will submit incident reports for each within 7 days of resident hospitalization. LPA observed 6 of 9 residents present. resident care needs appear to be met by 2 caregivers. 3 of 9 residents are currently not present and are at the hospital. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted. Report reviewed. Copy of report and appeal rights provided