502701194-6-9-2023-27-AS-KVIA-CSG6QF-20230603210036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701194
Report Date: 06/02/2023
Date Signed: 06/09/2023 10:36:05 AM

Document Has Been Signed on 06/09/2023 10:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	HOSPITALITY HOUSE		FACILITY NUMBER:	502701194
ADMINISTRATOR:	PADILLA, LORRAINE		FACILITY TYPE:	740
ADDRESS:	5400 KIERNAN AVENUE		TELEPHONE:	(209) 543-9275
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	80	CENSUS: 47	DATE:	06/02/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Lorraine Padilla		TIME COMPLETED:	04:30 PM

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On 06/02/2023, Licensing Program Analyst (LPA) Kimberly Viarella and Licensing Program Manager (LPM) Liza King made an unannounced post-licensing visit to this facility. Community Care Licensing (CCL) representatives met with the Designated Facility Administrator, Lorraine Padilla (Administrator’s Certificate # 6058496740, expiration date 08/23/2023). They explained the purpose of their visit and a brief interview followed. Census at the time was 47 with 18 in Memory Care and 29 in Assisted Living. The facility also had 11 residents receiving hospice services.

This facility was approved for 40 ambulatory, 25 non-ambulatory, 15 bedridden, and was approved for a hospice waiver for 40. It was also approved for dementia care. LPA confirmed the facility was operating within the scope of their license.

Upon entering the facility, LPA/LPM noted the delayed egress alarm sounded as required. LPA/LPM also tested the Fire Exit in Memory Care and it too functioned properly.

The facility’s kitchen was inaccessible to residents and was locked when not staffed. The LPA and LPM inspected the refrigerator and pantry areas and found expired tortilla chips and bread sticks, as well as leftovers that were not labeled or dated. These items included meats, fruits, cookies and a pie. Once this was brought to the Designated Facility Administrator’s attention, staff were assigned to purge any expired or unlabeled items. This task was completed prior to the completion of the inspection. The LPA inspected the corrected food supply and found 2 days of perishable and 7 days of non-perishable groceries present at this time.

LPA/LPM observed that 2 of the kitchen trash cans did not have the required lids. The Designated Facility Administrator repaired/replaced them and reached compliance prior to the completion of the inspection.

LPA noted that all fire extinguishers and kitchen hood were inspected by Jorgenson Co on May 19, 2023. At this time, the LPA also observed a sufficient number of smoke/carbon monoxide detectors to be in compliance.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HOSPITALITY HOUSE	FACILITY NUMBER: 502701194
	VISIT DATE: 06/02/2023

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LPA noted that the dining room, living room and all common areas had sufficient furniture, furnishings, and lighting at this time, to be in compliance. LPA/LPM observed all of the required signage: License, Administrator’s Certification, Personal Rights, Facility Sketch, Emergency Disaster Plan, and Emergency/Resource Numbers. LPA also observed posted menus and activity schedules for residents, no activities for the day scheduled until 2:00 PM. At 2:00 PM, LPA visited the Dining/Activity room and there was no BINGO game being facilitated.

The LPA inspected a sample of 18 resident bedrooms and found that more than half did not contain the required chest of drawers, night stand, chair, lighting and closet space to be in compliance. LPA/LPM also noted that 3 residents had oxygen in their rooms and did not have the required warning signage on their doors. This was brought to the Designated Facility Administrator’s attention, and she printed and posted the required signs prior to the completion of this inspection.

It was also noted by the LPA/LPM that the mattress observed in the resident rooms inspected were encased in clear shipping plastic instead of the required mattress covers. This was brought to the Designated Facility Administrator’s attention, and they immediately sent someone out to purchase enough mattress covers to accommodate each bed.

During the inspection, LPM pulled an emergency pull-cord on 2 separate occasions to check response time. The first time a caregiver responded to an Assisted Living room in 5 minutes and 57 seconds. The second time a caregiver responded to a Memory Care room in 2 minutes and 5 seconds.

The LPA observed that all of the bathrooms inspected all contained grab bars and non-skid surfaces in the showers. Paper towels, liquid hand soap dispensers and trash cans with lids were also present in each bathroom. The LPA measured the hot water temperature in the bathroom to the left of the main entrance. LPA noted that it measured 105 degrees Fahrenheit and was therefore in compliance. LPA inspected all of the cabinets to ensure that all toxic cleaning agents were inaccessible to residents in care.

While inspecting one of the shower rooms, LPA observed 6 shaving razors in one of the medicine cabinets on the Assisted Living Side. This was brought to the attention of the Designated Facility Administrator and they immediately disposed of them returning the room to compliance.

The linen closet was inspected next and the LPA found a sufficient amount of linens for the residents in care at this time.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HOSPITALITY HOUSE	FACILITY NUMBER: 502701194
	VISIT DATE: 06/02/2023

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The LPA then asked to be shown where the medication was kept. The Designated Facility Administrator unlocked the Medication Room. The LPA/LPM, the Resident Care Director, Sabrina Duarte, explained their procedures with regard to medication logging, storage, dispensing and destruction. LPA inspected medications and log/EMAR and found that the start date for new meds was being omitted from the CMDR. This was brought to the RDO’s attention and RDO stated she would do additional training on this procedure. First Aid kit was also inspected and found to be in compliance.

RDO scheduled a pharmacy audit with Vibrant on 06/12/23, prior to the completion of this inspection.

LPA/LPM inspected the exterior of the building. Gates on either side of the facility were observed to be locked from the inside. LPM explained that it was a safety risk as it did not allow emergency personnel access and that the gates needed to be able to be opened from either side. The Designated Facility Administrator said that it would be fixed as soon as possible.

LPA/LPM observed 5 screens that needed to be repaired/replaced: 1 on the left side, 2 in the rear, and 2 on the right side of the facility. It was also observed by the LPA/LPM that the gutters needed to be cleaned as stems and other debris could be seen.

LPA/LPM also noted 3 medical beds, an armoire, microwave, folding chair, painting, and standing lamp discarded on the left side of the facility. The Designated Facility Administrator informed LPA/LPM that they had contacted a junk removal organization. LPA/LPM also observed a stack of medical equipment, bed frames, mattresses and debris stacked behind the overflowing dumpsters on the right side of the facility. LPM reminded Designated Facility Administrator that the lids on dumpsters must be able to close, per regulation. LPA inspected the Emergency/Disaster kit and found it to be in compliance at this time.

LPA/LPM conducted a Records Review of 5 resident files. All were in compliance however Pre-placement Appraisals need to be kept with the individual resident's file going forward. A review was also completed of 4 Staff files. At the time, they too were in compliance.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/09/2023 10:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HOSPITALITY HOUSE	FACILITY NUMBER: 502701194
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)

87307 Personal Accommodations and Services This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	(A) A bed for each resident,...Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Rubber sheeting shall be provided when necessary. (B) Bedroom furniture, which shall include...(C) Clean linen... pillow cases, mattress pads, bath towels, hand towels and wash cloths. (F) Basic laundry service (washing, drying, and ironing of personal clothing). Based on observation and interview the licensee did not comply with the section cited above in 9 out of 18 rooms inspected where nightstands, dressers, and chairs were missing along with mattress covers and pads. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	The licensee will provide the required mattress covers and pads for each resident bed and ensure that each resident has the required nightstand, chair, and chest of drawers. This will be completed by 06/30/2023. If completed sooner, Licensee may contact Kimberly Viarella at kimberly.viarella@dss.ca.gov.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation The facility shall be clean, safe, sanitary, and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above when the LPA observed 5 window screens that needed to be repaired/replaced along with observing the dusty/dirty overhead air vents throughout the facility which were surrounded by dark stains. LPA also noted that the gutters were also clogged with twigs and debris. There was also debris surrounding the exterior of the building to include: 3 medical beds, dresser, picture frame, standing lamp, wheel chair... which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	Licensee to repair/replace screens, clean gutters, and remove debris by 06/30/2023. Licensee will notify Kimberly Viarella at kimberly.viarella@dss.ca.gov upon completion.

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: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HOSPITALITY HOUSE	FACILITY NUMBER: 502701194
	VISIT DATE: 06/02/2023

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During the course of the file review, LPM observed 3 falls documented in R1s file and no reappraisal. In addition, the facility was unable to provide documentation of of incident reports submitted to CCL. R5 eloped from the MC area and no reappraisal was documented to provide additional interventions. This incident was reported to CCL. The Administrator and Resident Care Director were provided TA on reassessing residents when their is a change in condition, updating the service plan, and reporting requirements. Additionally, TA was provided regarding suspected elder abuse, reporting and the completion of proper forms.

The following deficiencies were observed or cited during today's inspection per California Code of Regulations, Title 22.

Exit interview conducted with Designated Facility Administrator, Lorraine Pallido, and copy of report and Appeal Rights were left at the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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