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13 | On 04/03/2025 at 2:35 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Caregiver, Liza Sanchez to deliver the findings of above allegations. LPA explained the purpose of the visit with Liza Sanchez. Liza Sanchez phoned the Licensee/Administrator, Anabelle Galera to inform. Anabelle Galera was unavailable to come to the facility. Anabelle authorized Liza Sanchez to sign the document.
During the investigation, the Department obtained the following documents from the facility – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, Physicians orders, narrative charting, medication worksheets. The Department interviewed W1, S1, S2, S3, and S4.
LIC9099-C Continued...
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32 | LIC9099-C (Page 3)
S2 stated "we always gave R1 water. Sometimes R1 would refuse...daughter brought a lot of drinks. S2 stated, "we would give R1 cranberry juice, give R1 drink, like 8oz, sometimes R1 would have 3 glasses of 8oz. S2 stated that most of the time, R1 would be in TV room or their room. R1 would be in their room watching movie, iPad and R1's daughter would call her on her iPad. S3 stated that most of the time, R1 would be in TV room or their room.
On 11/14/20204, the Department interviewed S1. S1 stated that R1 started spitting in 2022. There was a speech evaluation with John Muir Medical. When R1 would start spitting she would go back to her room. S1 stated, "...not fair for other residents when R1 spit food out and in front of other residents. R1 started spitting at clients/staff, spit over the walls, spitting food and saliva. S1 stated that R1 was kept in the room, then come out to eat meals, whereby R1 was placed at a table behind wall on the other side of wall.
Based on the Departments observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations Staff did not follow medical professional's prescribed orders and Staff isolated resident in care are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview conducted. A copy of this report and appeal rights provided |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/17/2025
Section Cited
CCR
87465(d) | 1
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7 | 87465 Incidental Medical and Dental Care
(d)If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:
This requirement is not met as evidence by:
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7 | Administrator will read the regulation and self-certify understanding and will comply. In addition, conduct In-Service training with all staff on following doctor's orders including but not limited to CPAP machines/masks. |
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14 | Based on observations, interviews and record reviews, the licensee did not comply with the section cited above in by not following R1’s doctor’s orders with administering prescribed medication orders including but not limited to daily use with a CPAP machine and CPAP mask during sleep, which poses a potential health, safety or personal rights risk to persons in care. | 8
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14 | Administrator will submit self-certification, training topic and synopsis of material covered and staff training sign-in sheet to CCLD by POC due date. |
Type B
04/17/2025
Section Cited
CCR
87468.2(a)(8) | 1
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7 | 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment,
humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement is not met as evidence by:
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14 | Based on observations, interviews and record reviews, the licensee did not comply with the section cited above in by isolating R1 from other residents during meals, watching television which poses a potential health, safety or personal rights risk to persons in care. | 8
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13 | On 04/03/2025 at 2:35 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Caregiver, Liza Sanchez to deliver the findings of above allegations. LPA explained the purpose of the visit with Liza Sanchez. Liza Sanchez phoned the Licensee/Administrator, Anabelle Galera to inform. Anabelle Galera was unavailable to come to the facility. Anabelle authorized Liza Sanchez to sign the document.
During the investigation, the Department obtained the following documents from the facility – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, Physicians orders, narrative charting, medication worksheets. The Department interviewed W1, S1, S2, S3, and S4.
LIC9099-C Continued...
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32 | LIC9099-C (Page 10)
On 10/03/2024, the Department interviewed S2, S3 and S4. S2 stated that they would change R1's diaper in the mornings, lunch and dinner. S3 stated that they changed R1's diapers and that R1 needed 2 people to assist. S3 further stated that they checked R1's diaper 3-4 times a day. Checked R1 diaper after breakfast and change R1's diaper at night. S4 stated that R1 could not stand up good. But they would change R1's diaper at night every 2hrs.
On 11/13/2024, the Department interviewed S1. S1 stated that Staff check all clients at night, and that Caregiver would take R1 to the bathroom every 2-3 hours. On 10/03/2023, the Department interviewed S1 who stated that staff would change R1s clothes every day and that they would change R1's diaper in the mornings, lunch and dinner. S2 stated that R1's diapers were changed and that R1 needed 2 people to assist. S2 stated that they checked R1's diaper 3-4 times a day, checked R1s diaper after breakfast and change R1's diaper at night. No information emerged to contradict the facility.
Allegation: Staff did not ensure resident was hydrated
Investigation Finding: Unsubstantiated
On 10/03/2024, the Department interviewed S2, S3 and S4. S2 stated that they would give R1 water and juice 4x's a day with breakfast, lunch, dinner and in between. S3 stated "we always gave R1 water. Sometimes R1 would refuse...daughter brought a lot of drinks. S3 stated, "we would give R1 cranberry juice, give R1 drink, like 8oz, sometimes R1 would have 3 glasses of 8oz.
LIC9099-C Continued...
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/17/2025
Section Cited
CCR
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(b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: (A) Dementia care, including, but not limited to, knowledge about hydration, nutrition, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living;
(B) Recognizing symptoms that may create or aggravate behavioral expression, as defined in Section 87101, Definitions, including, but not limited to, dehydration, urinary tract infections, and problems with swallowing; and
This requirement is not met as evidence by:
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14 | Based on observations, interviews and record reviews, the licensee did not comply with the section cited above in by providing to R1, the "Care of persons with Dementia", by recognizing symptoms that may create or aggravate behavioral expression, including, but not limited to, dehydration, urinary tract infections, and problems with swallowing; and spitting which poses a potential health, safety or personal rights risk to persons in care. | 8
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14 | Administrator will submit self-certification, training topic and synopsis of material covered and staff training sign-in sheet to CCLD by POC due date. |
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