405800361-1-20-2023-29-AS-KBUY-CNDLQC-20230124075717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800361
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:56:09 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2022 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20220411100823

FACILITY NAME:	WYNDHAM RESIDENCE		FACILITY NUMBER:	405800361
ADMINISTRATOR:	JODI BELTRAMA		FACILITY TYPE:	741
ADDRESS:	222 S. ELM STREET		TELEPHONE:	(805) 474-7260
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	72	CENSUS: 51	DATE:	01/20/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jodi Beltrama, Administrator		TIME COMPLETED:	10:58 AM

ALLEGATION(S):

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Staff do not respond to resident's call light in a timely manner
Staff did not have an Oxygen sign on the residents door

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Administrator Jodi Beltrama and explained the purpose of the visit.

LPA Olson conducted the initial 10-day complaint visit on 04/20/2022 from 11:00am to 1:40pm, LPA toured the facility, rooms, collected records and conducted interviews with staff at 11:00am, 12:30pm, and 12:45pm and residents. LPA De Leon conducted interviews with staff on 12/10/2022 at 11:17am, 11:40am, and 12:18pm. LPA conducted interviews with residents on 01/03/2023 at 2:39pm, 2:42pm, 3:22pm, 3:30pm and 3:46pm. LPA De Leon reviewed records on 01/03/2023 at 1:00pm.

Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 29-AS-20220411100823

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 01/20/2023

NARRATIVE

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On the allegation: Staff do not respond to resident's call light in a timely manner. LPA reviewed the call light/pendant records for R1, LPA found during the dates of 03/09/2022 to 04/05/2022. R1 had a total of 27 calls. 8 calls were over 10 minutes. The dates and length of those calls were 03/09/2022 for 10 minutes 31 seconds (10:31), 03/09/2022 for 15:48, 03/09/2022 for 35:18, 03/10/2022 for 12:04, 03/11/2022 for 41:13, 03/28/2022 for 10:27, 04/01/2022 for 29:36, and on 04/03/2022 for 40:36. Staff interviewed were not able to recall why those calls were not acknowledged or cleared timely. Staff interviews stated sometimes the call light/pendants were not working properly and/or if you walk-in on an emergency you need take care of that first then clear the call light/pendant after you helped the resident. Staff interviewed stated the facility was experiencing outbreaks of Covid, Outbreak of norovirus and were short staffed when the facility had call offs during this time. Interview with witness stated that R1 complained the call pendant was not being answered. Based on the evidence the allegation is deemed Substantiated at this time

On the allegation: Staff did not have an Oxygen sign on the resident’s door. LPA Olson observed 1 resident room without an oxygen sign on the door. Witness stated they did not see an oxygen sign on the door when they were present at the facility. Staff stated they do have oxygen signs on the resident’s doors but there is one resident that takes the signs down. Staff stated they are now hanging the sign higher up so it cannot be taken down so easily. Based on the evidence the allegation is Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20220411100823

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/23/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	(f)Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).7464(f)(1) This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to review all call systems to make sure they are all working properly, review pendant logs, emergency pull cords and telephone alarms for calls more then 15 minutes in duration
	8 9 10 11 12 13 14	Based on record review the licensee did not comply with the regulation above. R1 pressed alarm pendant and waited 10-45 minutes for help on 8 occasions to receive services which posses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	and investigate why they are taking place and fix any issues discovered. Provide a plan going forward on how calls will be answered timely. Provide training to all staff on policy and procedures for answering calls timely and backup plans for calls to be answered when floor staff is busy and cannot provide assistance timely. Provide copy of plan and training to CCL.
Type B 01/27/2023 Section Cited CCR 87618(b)(3)(B)	1 2 3 4 5 6 7	(b)In addition to Section 87611(b), the licensee shall be responsible for the following:(3)Ensuring that the use of oxygen equipment meets the following requirements: (B)"No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to review and train all staff on regulation 87618. Make sure a list of residents with oxygen is available to staff and that a sign is posted when required, and staff will monitor that
	8 9 10 11 12 13 14	Based on LPA observation the licensee did not comply with the regulation above. A resident room did not have an oxygen sign present which possess a potential safety risk to residents in care.	8 9 10 11 12 13 14	the signs continue to be posted. Send proof of training to CCL

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2022 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20220411100823

FACILITY NAME:	WYNDHAM RESIDENCE		FACILITY NUMBER:	405800361
ADMINISTRATOR:	JODI BELTRAMA		FACILITY TYPE:	741
ADDRESS:	222 S. ELM STREET		TELEPHONE:	(805) 474-7260
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	72	CENSUS: 51	DATE:	01/20/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jodi Beltrama, Administrator		TIME COMPLETED:	10:58 AM

ALLEGATION(S):

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Staff do not wear masks properly
Staff are not following COVID guidelines
Resident left in soiled diapers for an extended amount of time
Resident's rooms are dirty
Resident left on the floor for an extended amount of time
Staff are not properly trained to work with residents

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20220411100823

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 01/20/2023

NARRATIVE

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On the allegation: Staff do not wear masks properly. LPA’s interviewed staff, residents and witness which revealed that all staff wear masks properly at the facility all the time. Masks are provided at entry of facility to all staff and visitors entering. LPA Olson observed masks being worn by all staff. LPA De Leon observed staff wearing masks. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Staff are not following COVID guidelines. LPA Olson conducted a visit and upon arrival she was screened for Covid-19 by front desk staff prior to entry into the facility, staff were wearing masks properly and signs for covid-19 were hung in the common areas. Residents stated the facility is cleaned and wiped down regularly. Staff stated the facility was cleaned and disinfected regularly, masks were mandatory, and everyone was following Covi-19 guidelines. Based on the lack of evidence the allegation is deemed Unsubstantiated at this time.

On the allegation: Resident left in soiled diapers for an extended amount of time. LPA interviewed staff which revealed R1 was not on a care plan for incontinence care when R1 moved into the facility. R1 took care of R1’s own needs with little to no assistance. Staff completed rounds every 2 hours R1 had a change in condition in the beginning of April 2022 at which time R1 needed additional help with R1’s incontinent needs and briefs were necessary. R1 became bed bond on hospice services and went to 1-hour checks at that time. Hospice records recorded 1 incident of the resident being wet on hospice visit but no timeline was given to state this had been for an extended amount of time. R1’s medical records do not state any rashes or sores were present. Based on the lack of evidence this allegation is Unsubstantiated at this time.

On the allegation: Resident's rooms are dirty. LPA interviewed staff, residents, and witness which revealed the facility was clean, the rooms were cleaned regularly by caregivers and housekeeping staff and the linens were changed weekly or more if needed. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20220411100823

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 01/20/2023

NARRATIVE

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On the allegation: Resident left on the floor for an extended amount of time. LPA interviewed staff, residents and witness which did not reveal anyone being left on the floor for an extended amount of time. Staff stated they do 2-hour checks for most Assisted Living residents some residents can be every hour and every 30 minutes due to being ill, declining health, hospice or being a fall risk. The staff stated the residents have a pendant to push if help is needed before the regular rounds are done. Staff stated they do not remember R1 being on the floor for an extended amount of time. Based on the lack of evidence the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff are not properly trained to work with residents. LPA interviewed Staff, Residents and witness which revealed the staff providing care to the residents do a good job and are trained properly on resident care. Staff training records reviewed; staff are meeting the training regulations. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to the Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

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