405800987-10-10-2024-29-AS-KBUY-DACPBR-20241024111045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800987
Report Date: 10/10/2024
Date Signed: 10/10/2024 12:27:42 PM

Unsubstantiated

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
01/29/2024 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20240129103742

FACILITY NAME:	IRENE'S BOARD & CARE		FACILITY NUMBER:	405800987
ADMINISTRATOR:	ANGELITA O. MARAVILLAS		FACILITY TYPE:	740
ADDRESS:	220 VIA PROMESA		TELEPHONE:	(805) 227-0276
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	6	CENSUS: 4	DATE:	10/10/2024
		UNANNOUNCED	TIME BEGAN:	07:00 AM
MET WITH:	Licensee/Administrator, Angelita Maravillas		TIME COMPLETED:	01:03 PM

ALLEGATION(S):

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Staff are not following infection control practices.
Staff are not properly trained.
Staff are unable to communicate with residents due to language barrier.
Staff did not provide adequate food service.
Staff did not meet residents’ medical needs.
Staff did not accommodate resident for appointments.
Staff did not meet resident’s dietary needs.

INVESTIGATION FINDINGS:

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At 0:00 am on 10/10/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct a new complaint investigation visit, and issue final finding on two separate older complaints. LPA met with Licensee/Administrator, Angelita Maravillas, announced who he is and the reasons for the visit.
Staff are not following infection control practices.

As to the allegation of, “Staff are not following infection control practices.” I was alleged that facility staff do not utilize Personal Protective Equipment (PPE) or proper infection control, nor proper food handling, and isolation in the event of outbreaks. It was discovered through observations, and interviews on 02/02/2024, LPA Jeffries observed ample supply of PPE on hand in the facility living room cabinet and facility garage storage area. On 02/02/2024, LPA Jeffries conducted interviews of Staff 1 (S1) and (S2), who both stated they had been trained in infection control within the past year. S1 and S2 both stated that they understood infection control and COIVD+ isolation practices.
CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240129103742

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: IRENE'S BOARD & CARE	FACILITY NUMBER: 405800987
	VISIT DATE: 10/10/2024

NARRATIVE

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On 02/02/2024 LPA Jeffries observed lunch meal preparation and service and noted staff meeting infection control practices and regulation requirements (87555) pertaining to food preparation. LPA noted that the facility has had a total of one COIVD+ outbreak, on 08/18/2022 with no issues and followed all COVID+ recommend precautions during that outbreak, including contact and communications with local Public Health Officials. LPA Jeffries observed infection control training documentation for S1 on dates annual for 4 years including last training on 07/28/2023, and S2 for the same dates, 4 years including last training on 07/28/2023. LPA also noted that Facility Administrator is a currently licensed Register Nurse, with current training for infection control practices. At this time there is not enough evidence to support the allegation of, “Staff are not following infection control practices.” and is unsubstantiated at this time.

As to the allegation of, “Staff are not properly trained.” It was alleged that staff do not have proper training for lifting, assisting non-ambulatory residents, dementia care. It was discovered through documentation, observations, and interviews, on 02/02/2024, LPA conducted interviews with S1 and S2 who both stated that they are current on 20 or more hours of annual training, including 8 hours of dementia specific training. On 03/08/2024, LPA observed training records for in-service Hoyer Lift Training for S1 on 11/01/2016, and S2 on 12/02/2018. S1 stated that they have more than 10 years’ experience in caregiving with this population, and S2 stated they have more than 25 years’ experience in caregiving with this population. On 02/02/2024, LPA Jeffries observed Residents 1-2 being assisted from living room by S2 with no issues. On 02/02/2024, LPA conducted an interview with Administrator, Angelita Maravillas, who is currently a licensed Registered Nurse, who conducts in-house training for all staff, who stated all staff are experienced and trained. At this time there in not enough evidence to support the allegation of, “Staff are not properly trained.” and is unsubstantiated at this time.

As to the allegation of, “Staff are unable to communicate with residents due to language barrier.” It was alleged that; Residents and their families do not have access to staff that fluently speak English. It was discovered through interviews on 02/02/2024 LPA Jeffries conducted interviews with S1, S2, and Administrator. LPA noted that all interviews were conducted in English. LPA noted that Administrator and S2 have a primary language of Tagalog, and a secondary language of English in which both are proficient. S1 has a primary language of English and only understands Tagalog however does not speak Tagalog. Both Administrator and S1 reside as live-in caregivers at the facility and one or both are available at all times. At this time there is not enough evidence to support the allegation of, “Staff are unable to communicate with residents due to language barrier.” and is unsubstantiated at this time. CONTINUED on LIC9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240129103742

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: IRENE'S BOARD & CARE	FACILITY NUMBER: 405800987
	VISIT DATE: 10/10/2024

NARRATIVE

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As to the allegations of, “Staff did not provide adequate food service.”, and “Staff did not meet resident’s dietary needs.” It was alleged that, 15 hours are to pass between dinner and breakfast and meals provided are repetitive and lack diversity which often consist of frozen dinners, sandwiches, canned fruits/vegetables. It was discovered through interviews, observations, and documentation that on 02/02/2024, LPA Jeffries conducted interviews with Residents 1-4 (R1, R2, R3, and R4). R1 stated that they normally eat dinner between 4:30pm and 6:30pm. R1 stated that the facility meals are good. R1 stated that the facility provides breakfast in the morning shortly after they get out of bed between 7:00am and as late as 9:00pm. R1-R4 all stated they have no issues with the food service at the facility and can get snacks as requested. On 03/08/2024, LPA Jeffries conducted a visit and noted that the dinner service had not yet been started at 4:00pm when LPA left the facility. On 02/02/2024, LPA conducted an interview with S1, who stated the current residents are provided meals in the morning when they get up and its not always at the same time. S1 stated the times vary between 6:00am and 9:00am for breakfast. S1 stated that dinner is planned to be prepared at 5:00pm but staff will prepare it earlier depending on Residents requests and needs. LPA Jeffries noted that facility meets food regulation requirements on 02/02/2024 and all past Licensing inspections for the last 4 years. LPA reviewed R1-R5’s LIC602’s (Physicians Reports) and noted that no resident (R1-R5) had any noted dietary restrictions. At this time there is not enough evidence to support the allegations of, “Staff did not provide adequate food service.” and“Staff did not meet resident’s dietary needs.” and both are unsubstantiated at this time.

As to the allegation of, “Staff did not accommodate resident for appointments.” It was alleged that on approximately, 01/27/2024, R5 was not provided proper and timely medical care, on 01/27/2024, at 4:30pm being observed slumping in recliner as well as verbally non-responsive and mostly unaware of his surroundings. It was discovered through interviews and documentation that on 02/02/2024, LPA Jeffries interviewed Staff 1 (S1) who stated that on the day in question (01/27/2024) R5 had taken an “as needed” (Pro re nata or PRN) medication for agitation and that particular medication makes R5 very lethargic. On 02/02/2024 LPA Jeffries collected facility documentation of Narcotic Distribution Record which indicated that R5 had taken narcotic medication at 2:00pm on 01/27/2024 which also noted that the medication was “effective”. LPA observed facility Centrally Stored Medication Record which showed the PRN medication in question, was prescribed by Physician per regulations. LPA also observed facility Visitor Log In which did not show that R5 had any visitors on this day. LPA Jeffries noted that the visitation log for 01/27/2024, showed the individuals that visited the day of 01/27/2024 would have no knowledge of R5 medical conditions as well as when and what medications R5 were present and not knowing that the condition of R5 on 01/27/2024 did not require medical attention or appointments. At this time there is not enough evidence to support the allegation of, “Staff did not accommodate resident for appointments.” and is unsubstantiated at this time.

Exit interview, report read, and report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

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