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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803925
Report Date: 05/21/2021
Date Signed: 05/21/2021 04:51:48 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2020 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20201106103350
FACILITY NAME:AMEERA CAREFACILITY NUMBER:
486803925
ADMINISTRATOR:MONES, MA. JOWAHERFACILITY TYPE:
740
ADDRESS:2568 BOXWOOD LANETELEPHONE:
(925) 818-6415
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
05/21/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee/Administrator Ma Jowaher MonesTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Illegal eviction

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) K. Canela arrived at Ameera Care for the purpose of delivering findings on complaint # 21-AS-20201106103350. LPA met with Licensee/Administrator Ma Jowaher Mones.
The Department investigated the allegation of “Illegal eviction”. Interviews were conducted with 3 of 7 staff. A record review of Resident (R1)’s file, physician’s report, pre-appraisal, hospice care plan, relevant photographs, as well as the facility file were conducted.


Report continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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 7
Control Number 21-AS-20201106103350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: AMEERA CARE
FACILITY NUMBER: 486803925
VISIT DATE: 05/21/2021
NARRATIVE
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Licensee and Administrator (S1) stated in a written rebuttal statement that R1 was admitted to hospice on 10/10/2020 (R1 was placed on Hospice on 10/09/2020) and the facility explained to R1’s responsible person (RP) that R1 needed a private room to receive hospice care and the facility did not have a private room available at the time. S1 stated RP decided to search for a facility to accommodate R1’s needs (hospice care). S1 stated RP was referred to several facilities “in good standing and with private rooms” and RP declined. S1 stated, “it was not like [RP] was not given enough time to look for a more suitable home for [R1]”. Additionally, S1 stated “it was clear that from the time [R1] was put on hospice [RP] knew that we didn’t have a private room available, and the room where [R1] was staying ... was a temporary accommodation. Had it not been for [R1] being a hospice resident [R1] would still be at Ameera Care to this day”. RP stated they were not informed about hospice care residents in a shared room getting consent from the roommate to allow hospice providers to enter the shared room to provide care. RP stated if they were informed about this beforehand, then RP would have "never" placed R1 to facility.

After obtaining the “Release from Facility Liability” form created by Ameera Care facility, which concluded that the event had occurred as alleged, and conducting interviews which were consistent in their facts establishing the event had occurred and the facility did not follow the proper eviction procedures as regulated for Residential Care Facilities for the Elderly (RCFE) the allegation of “Illegal eviction” is substantiated.

Based on interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the allegation “Illegal eviction” is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. Appeal Rights Provided. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Licensee/Administrator Ma Jowaher Mones. Whose signature on this form confirms receipt of these documents.

Due to technical difficulties, reports were PDF and emailed to Licensee.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20201106103350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: AMEERA CARE
FACILITY NUMBER: 486803925
VISIT DATE: 05/21/2021
NARRATIVE
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The following allegation was reported for R1 of events leading up to the "illegal eviction": R1 was admitted into a shared room at La Paz Garden Manor facilityon 07/06/2020 (before change of ownership to Ameera Care effective 10/22/2020). On 10/08/2020, there was an incident involving R1 and roommate R2. The Reporting Party (RP) arrived late afternoon to the facility after receiving multiple calls from staff stating R1 was agitated, restless and refused their medication and lunch. At approximately 6:00 PM Staff (S2 & S3) and RP took R1 to their room to rest. R1’s bedroom door was found locked. S3 knocked on the bedroom door several times however R2 refused to unlock the door. S2 found the key to unlock the bedroom door and once unlocked, RP and staff partially entered to find R2 "brandishing a cane in a threatening manner refusing entry and wanting to call the police". R2 continued to refuse R1 to enter the room. RP stated they negotiated and convinced S2 & S3 to switch resident rooms temporarily to remove R1 from the shared room with R2 and moved into R3’s private room until R2 settled down. Staff (S1, S2, S3) confirmed incident occurred as alleged. RP stated they helped move some of R1's belongings into the private room on 10/08/2020 and left the facility around 7:30pm.

On 10/09/2020, R1’s Palliative Care Registered Nurse was contacted in the morning regarding the incident and R1’s decreased appetite. The Palliative Care RN evaluated R1 and R1’s Primary Care Provider (PCP) was contacted to request an order for a Hospice Evaluation. R1 was admitted under Sutter Hospice Care on 10/09/2020 due to primary diagnosis and decreased appetite. Prior to this, RP stated they felt “pressured” into putting R1 on hospice by the facility, even though R1 had not met the hospice criteria previously.
On 10/15/2020, it was reported RP received a video from S2 of a priest “blessing” and giving R1 their “last rites sacrament”. On 10/16/2020, RP arrived at the facility and found R1 “overly sedated, stiff and very rigid” with their “legs drawn up and heels were planted in the mattress”. RP discovered a pressure ulcer on R1’s right heel.
On 10/22/2020 Ameera Care became officially licensed (through a change of ownership). On 10/24/2020, R1 was moved back into the shared room with R2, since the facility allowed R1 to stay in R3’s private room as a “temporary accommodation”. RP began receiving calls from placement agencies for R1, but stated they were unaware of R1 being evicted. On 10/28/2020, RP was presented with a “Release from Facility Liability” form to be discharged from “La Paz Garden Manor” as of 10/30/2020 (in 3 days). RP was then informed the facility could not accommodate R1, a hospice care resident, due to R2’s responsible party not consenting to allow hospice care providers to enter R1 & R2’s shared room to provide care to R1. R1’s final day at Ameera Care facility was 10/30/2020.

Report continued on LIC9099-C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 21-AS-20201106103350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: AMEERA CARE
FACILITY NUMBER: 486803925
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2021
Section Cited
CCR
87224(a)
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87224(a) - Eviction Procedures (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required …This requirement was not met as evidenced by: Interviews conducted, and records reviewed...
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Licensee to review Eviction Procedures regulation 87224 and submit a written statement that they have reviewed the regulation, 87224 in full, and in the future Ameera Care will follow proper eviction procedures. Send written statement along with LIC9098 to Community Care Licensing (CCL) by POC due date to clear deficiency.
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Licensee/Administrator did not comply with regulation requirements regarding eviction procedures. Resident (R1) and their responsible person was never issued a proper 30 eviction notice as required by the regulation. This poses a potential health and safety risk to residents in care
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2020 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20201106103350

FACILITY NAME:AMEERA CAREFACILITY NUMBER:
486803925
ADMINISTRATOR:MONES, MA. JOWAHERFACILITY TYPE:
740
ADDRESS:2568 BOXWOOD LANETELEPHONE:
(925) 818-6415
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
05/21/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee/Administrator Ma Jowaher MonesTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Resident's needs were not met by the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) K. Canela arrived at Ameera Care for the purpose of delivering finding on complaint # 21-AS-20201106103350. LPA met with Licensee/Administrator Ma Jowaher Mones.
The Department investigated the allegation “Resident's needs were not met by the facility”. Interviews were conducted with 3 of 7 staff. A record review of Resident (R1)’s file, physician’s report, pre-appraisal, hospice care plan, relevant photographs, as well as the facility file were conducted.


Report continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 21-AS-20201106103350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: AMEERA CARE
FACILITY NUMBER: 486803925
VISIT DATE: 05/21/2021
NARRATIVE
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It was alleged "Resident's needs were not met by the facility" when facility was licensed as La Paz Garden Manor, due to the facility's alleged actions which resulted in Resident (R1) developing a Stage 2 Pressure Ulcer on their right heel of foot. R1 was admitted to La Paz Garden Manor on 07/06/2020. The facility later had a Change of Ownership became Ameera Care (officially licensed effective 10/22/2020). It was reported that the licensee/administrator was "pushing" R1's Responsible Party (RP) to place R1 on hospice in September 2020 as well as wanting to get antipsychotic medications prescribed for R1. RP stated they declined and R1 was evaluated on 09/12/2020 or 09/19/2020 and did not meet the requirements for Hospice admittance. It was reported there was an incident involving R1 and roommate R2, in which R2 locked R1 out of their shared room and R2 was "brandishing a cane in a threatening manner" while refusing R1, RP, and staff into the room. Staff (S1, S2, S3) confirmed the incident had occurred as R1 & R2 did not get along well. After the incident, it was reported R1 refused to eat and was then placed on Hospice Care under Sutter Hospice the next day (10/09/2020). On 10/16/2020, it was discovered by RP that R1 had developed a pressure ulcer on right heel (photos obtained). It was reported staff did not move R1 in two days (since 10/14/2020). It was reported that due to R1's primary diagnosis and not walking often after sustaining the pressure ulcer that R1 "forgot how to walk".
Additionally it was reported R1 was moved into resident (R3)'s private room due to the incident involving R1 & R2. Licensee/Administrator Staff (S1) stated RP was often contacted to assist with R1 such as bathing/showering, due to R1 being very "combative and agitated" with staff which was "overwhelming" for staff. It was reported that the Administrator was "pushing" to get antipsychotic medications and sedatives prescribed for R1 to manage the agitation and combativeness.
A statement from R1's Palliative Care Registered Nurse, who last visited R1 on 10/09/2020 (prior to hospice care), indicated R1 was on a medication regimen which was working well for R1. However, the facility staff seemed to not be following the exact regimen, which caused R1 to have behaviors (agitation).
A note dated 10/01/2020 indicated the Licensee/Administrator requested antipsychotic medications for R1 such as Seroquel and sedatives such as Ativan. The medications caused a "bad reaction" which resulted in R1 being sent to the Emergency Room due to low blood pressure and to rule out an infection. Additionally in the statement received by the Palliative Care RN, as R1 became incontinent the facility became more dependant on R1 being in adult diapers/briefs rather than being taken to the bathroom for toileting every 2 hours.

Report continued on LIC9099C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 21-AS-20201106103350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: AMEERA CARE
FACILITY NUMBER: 486803925
VISIT DATE: 05/21/2021
NARRATIVE
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A statement received from R1's Hospice registered nurse indicated they did not observe any concerns during their visits to Ameera Care. The Hospice RN stated the facility tried different medications to manage R1's behavior. Many meds were discontinued due to a trial and error. The hospice RN did not have information regarding antipsychotic (seroquel) and sedative (Ativan) medication. Per their statement, all of R1's medication was prescribed by a physician with Sutter Hospice and was given as prescribed. Hospice has a standing order for prescribing medications especially for pain management. The Hospice RN did not have any information regarding facility staff not wanting to assist R1 with toileting to the bathroom every 2 hours and relied on adult briefs/diapers instead. The Hospice RN stated if that were to have happened, it is possibly because R1 was incontinent & stiff (due to muscle contractures) and the facility "probably thought it was not safe to transfer to the bathroom because it could lead to a fall". The Hospice RN stated they had no concerns with the facility providing care to R1 and "the owner (Licensee Jowaher Mones) was a hospice nurse before, so there was no problem in coordinating care".
Licensee/Administrator stated she would evaluate R1 and recommend medications based on their need. Licensee stated they would consult with R1's PCP, neurologist, hospice care providers, as well as R1's responsible person. Licensee stated R1's medications were given as prescribed.

Additionally R1's hospice summary report dated 10/13/2020 entered by a Medical Director indicated R1 has a significant decline "in the last month" from being independently ambulatory without assistance, having a good appetite to rapid decline with difficulty walking and dramatically decreased appetite. R1 required 2-3 person assist with transferring or for personal care due to increased combativeness and agitation. The report noted R1 was at "high risk for skin breakdown now that [R1] is primarily bedbound, with rapid decrease in appetite the patient (R1) will become protein calorie malnourished which further increases risk of skin breakdown, infections and sepsis due to compromise of [their] immune system."

The Department has investigated the complaint alleging “Resident's needs were not met by the facility". Due to contradicting statements received, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Jowaher Mones Licensee/Administrator, whose signature on this form confirms receipt of these documents.

Due to technical difficulties, reports were PDF and emailed to Licensee.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7