Estancia del Sol.

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Lisa Hunt and was granted entry to the facility. Licensed capacity is (135) current census (118). LPA was accompanied by Administrator Lisa Hunt to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated office for residents/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care . Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (10) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (10) resident medications and (5) hospice files. LPA also reviewed (10) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Lisa Hunt.

For the allegation, Staff do not follow hand hygiene procedures. During staff interviews 6 out of the 6 staff stated they follow all hygiene procedure. During record review, LPA verify the facility staff have been properly train for hygiene procedure. During facility tour, LPA observed staff using proper hygiene procedures. For the allegation, Staff do not treat residents with dignity and respect. During staff interviews 6 out of the 6 staff stated they treat their resident with dignity and respect. During resident interviews 7 out of the 8 clients stated they are treated with respect and dignity. Based on the evidence found during the investigation, the three (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Lisa Hunt.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced case management visit. LPA Rico arrived at the facility to deliver findings on the compliant control 56-AS-20231107145012. LPA met with Administrator Lisa Hunt and granted entry to the facility. During the investigation, Community Care Licensing Department discovered that on 6/28/2023, S2 administered R1’s medication incorrectly. R1’s medication was supposed to be lowered to half of the normal dosage, but instead S2 increased R1’s dosage three (3) times the prescribed amount. Facility staff (2) admitted they committed a medication by providing R1 more medication that what was prescribed. Due to R1 medication error, the facility will be issue a deficiency. During today’s visit, one (1) Type A deficiencies to the facility were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report, LIC809, LIC809D, Appeal Rights were discussed and provided to Administrator Lisa Hunt.

The facility staff failed to observe R1’s change of condition when they were in R1’s bedroom completing the resident check between 8:30 AM and 8:45 AM. Based on the evidence discovered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because of the preponderance of evidence the standard has been met. During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D were discussed and provided to Administrator Lisa Hunt, along with a copy of the appeal rights. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 6/28/2023, S2 administered R1’s medication incorrectly. R1’s medication was supposed to be lowered to half of the normal dosage, but instead S2 increased R1’s dosage three (3) times the prescribed amount. Thirty-six (36) hours later R1 suffered a stroke and was transported to receive medical care. Based upon investigation, medication documentation did not substantiate that R1 stroke was due to the inaccurate medication dosage. The allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Lisa Hunt.

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Lisa Hunt and was granted entry to the facility. Licensed capacity is (135) current census (119). LPA was accompanied by Administrator Lisa Hunt to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated office for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care . Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (6) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (6) resident medications and (6) hospice files. LPA also reviewed (6) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Lisa Hunt.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to conduct a Health and Safety check at the facility. The Health and Safety check was completed at same time as the annual inspection. LPA met with Administrator Lisa Hunt and explained the reason for the visit. The Health and Safety check included overall observation of the facility inside and outside, including food supply, medications, physical plant, and residents in care. During kitchen tour, LPA found a tray of Jello uncovered in the refrigerator. The facility was issued a type B deficiency on the LIC809 annual inspection for not covering the Jello in the refrigerator. Based on the observations made during today’s visit, one (1) deficiency was cited on the annual inspection per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Administrator Lisa Hunt at the conclusion of the visit.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to Lisa Hunt, Executive Director.