Carefield Pleasanton

On 9/29/2023 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Assistant Executive Director, Eunice O'Farrell. During the course of investigation for complaint (#15-AS-20221229131014), the following deficiency was observed. Interview with staff (S2) revealed that facility did not always submit an incident report for R1's falls. LPA observed only 3 incident reports regarding R1's fall. However, R1 had other falls that was not reported to CCLD. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

On 7/14/2022 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Senior Executive Director, Parveen Singh and Assistant Executive Director, Eunice O'Farrell. LPA explained the purpose of the visit. Upon entry, LPA's temperature was checked and asked to fill out COVID-19 questionnaire on the automated kiosk. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor area. LPA observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All bathrooms were equipped with soap and paper towel. Hand washing posters were posted at bathrooms. During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPEs, food supplies, and paper supplies are sufficient. Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102. No deficiencies were cited on this date. Exit interview conducted. A copy of this report provided.

On 1/24/2025 at 12:50PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 1/20/2025. LPA met with Executive Director, Eunice O'Farrell and explained the purpose of the visit. Death report revealed that R1 was found unresponsive by staff and 911 was called. R1 passed away at the hospital on 1/15/2025 with cause of death unknown. LPA interviewed staff and reviewed documents including R1's physician's report, care plan, and facility notes. On 1/15/2025, staff found R1 looking pale and unresponsive while in bed. R1's physician's report revealed that R1 had long standing persistent fibrillation. Staff called 911 and R1 was transported to the hospital. Family notified facility staff that R1 passed away later that day at the hospital. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

Facility not allowing resident to receive phone calls. Interview with staff and residents revealed that residents are receiving phone calls. After reviewing phone logs, LPAs observed resident (R1) was receiving phone calls. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.

On 1/24/2025 at 2:25PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 1/23/2025. LPA met with Executive Director, Eunice O'Farrell and informed her the reason for the visit. Based on the incident report received on 1/23/2025, med tech noticed that R1 was not in his room and was not able to be located during safety status check around 7:20PM on 1/16/2025. The door located in the back parking lot was left propped open while a vendor was bringing in their equipment. Police department was notified and R1 was located by police. R1 was transported back to the facility by R1's family/POA. During visit, LPA interviewed staff and reviewed R1's file including physician's report, service plan, care notes, and incident report. R1's physician's report stated that R1 cannot leave the facility unassisted. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

Facility staff did not attend to residents in a timely manner after falling. After reviewing a sample of resident's pull cord records, LPA observed staff response time to pull cords is less than 16 minutes. Interview with staff indicated there hasn't been an incident where pull cord response time is an hour or more. Facility staff leave residents in urine and feces for extended periods of time. Interview with staff revealed that resident's diaper checks are 2-3 hours and some residents are checked more frequent. Staff stated there hasn't been an incident where resident is left in soiled diaper for an extended periods of time. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.

On 1/12/2023 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Executive Director, Eunice O'Farrell. During the course of investigation for complaint (#15-AS-20230329161525), the following deficiency was observed. LPA reviewed Guardian and observed S1 is not fingerprint cleared. Civil penalty of $500 is being assessed. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.

Resident suffered multiple falls resulting in injuries . Interview with staff revealed that R1 had six falls while living at the facility in which four falls resulted in injuries or minor injuries. However, after R1’s fall on 5/22/2022, the facility raised R1’s level of care from a two to a four which increased resident checks to eight times, R1 is checked every 30 minutes due to fall risk, and fall alarms was installed in R1’s room. Resident was not provided assistance with toileting needs Interview with staff indicated that toileting needs are checked at least every 2 hours. Staff have not witnessed resident's toileting needs were not met. Resident was not provided assistance with showering . Interview with staff revealed that R1 would sometimes refuse showers and staff come back at a later time to assist R1 with showers. Staff stated when a resident refused showers, it would be documented on the progress notes. Inadequate staffing to meet the needs of the residents in care . LPA reviewed staff scheduled and observed AM shift have 4-5 caregivers and 1 med tech, PM shift have 4 caregivers and 1 med tech, and NOC shift have 2 caregivers and 1 med tech. Interview with staff revealed that besides the caregivers and med techs, a manager is on duty for both AM and PM shift seven days a week. Staff did not respond to resident's call bell . LPA reviewed a sample of resident's pull cord records and observed pull cord incidents from R1 were responded by facility staff. Resident cannot easily use pull cord . LPA observed R4 demonstrated how to pulled on the pull cord beside the bed and was able to pull the pull cord. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided. 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 Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.

On 12/30/2022 at 10:20AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with Assistant Executive Director, Eunice O'Farrell. LPA toured facility including but not limited to the resident bedrooms, bathrooms, common area, kitchen, and outdoor area. Facility temperature was maintained at 69 degrees F. Hot water temperature was measured at 120 degrees F in a resident's bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility order food supplies weekly. Refrigerator was 36 degrees F and freezer was -3 degrees F. Resident's medications were kept locked in the medication room. Smoke detectors are interconnected with sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full. There are no accessible bodies of water observed. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report was provided.

On 7/28/2022 at 12:55PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 7/26/2022. LPA met with Business Office Director, Jocelyn Sanjuan. Senior Executive Director, Parveen Singh arrived a couple hours later. Death report dated 7/26/2022 stated that R1 was found unresponsive on 7/22/2022 and staff called paramedics. R1 has a DNR on file. R1 passed away at the facility on 7/22/2022. During visit, LPA reviewed R1's file and observed physician's report dated 7/15/2022 stated that R1's primary diagnosis was Cerebral Infarction affecting right dominant side, Dysphagia, and CHF. R1's secondary diagnosis was Chronic Kidney Disease and Vascular Dementia. Facility notes indicated that R1 did not eat much for a couple days prior to passing. Interview with staff indicated that R1 did not eat much prior to moving into the facility. Paramedics pronounced death on 7/22/2022. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.