Inspection Reports for Epic Assistance Care Home I

An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements at the facility.

The inspection found the facility generally clean and well-maintained with appropriate resident care and documentation. However, three Type B deficiencies were cited related to water temperature exceeding safe limits, lack of current CPR/First Aid certification for two staff members, and improper posting size of the RCFE Complaint poster.

The inspection was an unannounced Required 1 Year Inspection conducted to evaluate compliance with licensing regulations for the facility.

The facility was found to be in compliance with all applicable regulations with no deficiencies issued. The environment, safety measures, emergency preparedness, and resident care conditions were all satisfactory.

The inspection visit was conducted as an unannounced investigation of deficiencies related to allegations in complaint reference #22-AS-20230217143103.

One deficiency was cited for failure to report a COVID-19 outbreak involving multiple staff members and one resident in November 2022 to the Department as required by regulation.

The visit was triggered by a complaint alleging failure to report a COVID-19 outbreak. The deficiency was substantiated based on interviews and record review.

An unannounced complaint investigation visit was conducted following a complaint received on 2023-02-17 regarding multiple allegations including questionable death, unauthorized alcohol given to a resident, failure to address and notify changes in resident condition, lack of dignity and supervision, and COVID-19 safety protocol violations.

The investigation found all allegations except one to be unfounded or unsubstantiated. The allegation that staff did not follow proper COVID-19 safety protocols was substantiated, with staff members who tested positive kept on active duty without reporting a critical staffing shortage. Other allegations including questionable death, unauthorized alcohol provision, failure to notify or address resident condition changes, lack of dignity, and inadequate supervision were found to be without reasonable basis.

The complaint investigation was triggered by multiple allegations including questionable death, unauthorized alcohol given to a resident, failure to address and notify changes in resident condition, lack of dignity and supervision, and failure to follow COVID-19 safety protocols. The investigation concluded that all allegations except the COVID-19 safety protocol violation were unfounded or unsubstantiated.

An unannounced Required – 1 Year Annual inspection was conducted to evaluate compliance with licensing regulations at the facility.

The facility was found to be clean, in good repair, and well maintained with adequate safety measures. However, deficiencies were cited related to outdated physician reports for residents with dementia and lack of documented required staff training.

The visit was an unannounced inspection conducted to document deficiencies observed during the initial investigation of allegations in complaint reference #22-AS-20230217143103.

Two deficiencies were cited: the fire extinguisher maintenance was outdated by six months, and four out of five physician reports for residents with confirmed dementia diagnoses were outdated by up to two years. Additionally, a technical violation advisory was issued for admitting a resident with a Stage 3 dermal ulcer without an exemption request, and a technical assistance advisory was issued for outdated certificates posted in the facility.

The visit was triggered by a complaint investigation referenced as #22-AS-20230217143103.

The visit was a scheduled follow-up for the purpose of completing the pre-licensing for the facility.

The Licensing Program Analyst observed that the facility had installed a fireplace screen and nightlights in bedrooms, hallways, and kitchen to secure nighttime circulation. All elements verified appeared to be in compliance and the facility was ready to be licensed.

The visit was conducted for the purpose of pre-licensing verifications required for a change of ownership at the facility.

The facility was toured and found generally well maintained with adequate safety features and supplies; however, several items needed correction before licensing, including securing cleaning supplies, installing a screen in front of the fireplace, adding night lights, and securing medications and toxic substances in the staff bedroom.

The visit was conducted as an original licensing evaluation for the EPIC Assistance Care Home facility, including a telephone interview to verify the applicant/administrator's understanding of California Code Title 22 Regulations and readiness for licensing.

The applicant/administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. No deficiencies or violations were noted in the report.