Office review·October 29, 2024

A Subsequent Non-Compliance Meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Bethany Moellers, Licensing Program Analysts, Julie Florio, and Licensee, Imelda Padema. The purpose of the Subsequent Non-Compliance Meeting was to discuss areas of non-compliance and ongoing observed concerns during inspection on September 19, 2024, in the of the operation of L & S Gentle Care II, facility #486803974. Facility was placed on a Non-Compliance Plan on 07/13/2023 and received Technical Support Provider (TSP) consultations on 08/14/2023 and 08/28/2023. Today, the Licensee were informed that further and/or repeat citations may result in extending the facility’s non-compliance plan or possibly administrative action. The legal administrative action process was explained to attendees. Items addressed in today's meeting include patterns of non-compliance in the following areas : 1. Fire Clearance/Live-in Staff : Staff shall not sleep or reside in un-permitted/uncleared rooms or facility communal areas, (see pictures). LPA Karina Canela cited for the same deficiency 07/10/2023 after numerous discussions regarding the same issue on 04/19/2023, 01/25/2023, 06/28/2022, 06/02/2022, 05/23/2022. 2. Staffing : Staff must be sufficient in numbers to provide adequate care and supervision to residents in care. 3. Staff Training : Staff m ust complete initial training hours prior to working independently with residents. 4. Staff Medication Administration Training: Staff shall be complete initial training hours prior to working independently with residents. Continued on LIC809C... Continued from LIC809... 5. Personnel Records : Staff records shall be complete with required documentation. 6. Client Records : Client records shall be complete with required documentation. 7. Administrator Qualifications and Duties : The administrator shall be present a sufficient number of hours to ensure facility is operating within compliance. 8. First Aid Requirements : The administrator shall ensure that all staff have proof of current First Aid given by American Red Cross. 9. Buildings and grounds : The s hed in backyard and storage room in the garage were both observed unlocked with chemicals inside, as well as chemicals and a bottle of alcohol in an unlocked cabinet in the laundry room. 10. Submission of requested documents by due dates Documents requested during September 19, 2024, facility visit were not provided to CCL. Below documents were requested again during today’s meeting and Licensees agrees to submit to CCL by 11/15/2024 : · LIC500 personnel summary and include all staff specific days/hours on shift, including administrator. · LIC9020 – Register of Residents Citations and Civil Penalties issued today : 1. Licensee was informed that a citation and an immediate civil penalty are being issued today for the personnel requirements violation observed during Case Management – Legal Non-Compliance quarterly visit conducted on September 19, 2024, due to staff files for S1 and S2 did not have proof of initial training hours completed and were observed working independently with residents. Upon interview with Licensee and staff, LPA discovered that the staff both started the day prior, 09/18/2024. Facility was cited for the same deficiency during Case Management – Legal Non-Compliance quarterly visits on 04/12/2024 and 7/17/2024. This is the second repeat of this violation within a 12-month period, (see LIC809D). Continued on LIC809C... Continued from LIC809C... 2. Licensee was informed that a citation is being issued today for a care of persons with dementia violation observed during Case Management – Legal Non-Compliance quarterly visit conducted on September 19, 2024, where Licensee did not ensure that R1’s physician ordered alcohol was kept in a secure place that is not accessible to persons in care. LPA observed an almost full 1.75-liter bottle of Seagram’s Extra Dry Gin on a shelf in an unlocked cabinet in the facility’s unlocked laundry room, along with a bottle of bleach and a bottle of laundry detergent. LPA further observed cleaning and toxic chemicals accessible to residents in care in the unlocked garage, unlocked storage room in the garage, and the unlocked storage shed in the backyard (see pictures), (see LIC809D). 3. Licensee was informed a citation is being issued for staff medication administration training due to upon observation, interview, and record review, LPA discovered that new staff (S1 and S2) passed medications to the residents in care the morning of 9/19/2024 without having completed any documented medication administration training. Further it was revealed that both staff were hired on 9/18/2024, (see LIC809D). 4. Licensee was informed a citation is being issued for resident records due to LPA observing numerous required documents either incomplete or missing from multiple residents’ records upon file review, (see LIC809D). The following documents were observed incomplete or missing from the indicated residents’ records: § Proof of Negative TB results: R1 § Admissions Agreement not signed and/or dated: R1 & R4 § LIC9172 - Functional Capability Assessment: R1, R2, R4, & R5 § LIC625 -- Appraisal/Needs and Services Plan: R1, R2, R4, & R5 § Consent for Emergency Medical Treatment: R1, R2, R4 § Centrally Stored Medication Destruction Record (CSMDR): R1 § LIC601 - Identification and Emergency Information: R1 & R4 Continued on LIC809C... Continued from LIC809D... 5. Licensee was informed a citation is being issued for staff living/sleeping in the un-permitted/uncleared room in the garage and communal areas of the facility due to LPA’s observation and staff interviews which confirmed this was occurring (see pictures), (see LIC809D). Licensee was informed to be in compliance at all times with fire clearance on file which does not include clearance for the structure in the garage. Licensee informed LPA that they are unable to have the structure permitted due to costs involved. Licensee was informed to contact local code enforcement to request written approval to use the room for storage only, followed by approval from the local fire department. If unable to get approval, Licensee has agreed to disassemble the structure in the garage. 6. Licensee was informed a citation is being issued for personnel records due to LPA’s observation, interviews and record review which revealed numerous required documents were either incomplete or missing from multiple staff members’ records as observed during file review and as noted below, (see LIC809D). · Proof of First Aid Certification: S1, S2, & S3 · Proof of CPR certification: S1 & S3 · LIC501: Job application: S1, S2, S5, S7, & S9 · LIC503: Health Screening: S1, S2, S3, S6, S7, & S10 · Proof of Negative TB results: S1, S2, S3, S4, S6, S7, & S10 · Initial Orientation and Training Hours: S1 & S2 · Initial Medication Administration Training Hours: S1 & S2 7. Licensee was informed a citation is being issued for administrator duties and qualifications due to LPA’s observations, interviews, and record review which revealed that adequate attention to the management and administration of the facility was not occurring as evidenced by the above noted deficiencies and that administrator had untrained staff working independently, (see LIC809D). The following deficiencies were observed and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation or the California Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Licensees and appeal of rights provided. Signature on form confirms receipt.