Inspection Reports for Pepper Tree Assisted Living

An unannounced annual inspection visit was conducted to evaluate compliance with licensing requirements for the Pepper Tree Assisted Living Facility.

The facility was found to be generally clean, in good repair, and compliant with most regulations including infection control and safety measures. However, deficiencies were observed and citations were issued, including an expired administrator certification.

An unannounced Required – 1 Year Inspection was conducted to evaluate compliance with licensing regulations at the Pepper Tree Assisted Living Facility.

The facility was found generally compliant with safety, medication, and hygiene standards; however, a deficiency was cited for not having a videoconferencing device dedicated for resident use, posing a potential personal rights risk.

An unannounced complaint investigation visit was conducted to investigate allegations that staff were not addressing pest infestation at the facility and that uncleared adults were working at the facility.

The investigation found that the facility had a pest control service agreement and was actively addressing pest infestation with regular treatments. All staff working at the facility had California background clearances. Therefore, both allegations were found to be unsubstantiated and no deficiencies were cited.

The allegations investigated were: 1) Staff are not addressing pest infestation at the facility, and 2) Uncleared adult(s) are working at the facility. Both allegations were found to be unsubstantiated based on interviews, observations, and records review.

An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tool.

The facility was found to be sanitary, appropriately furnished, and compliant with Title 22 regulations. Infection control practices, including screening protocols and PPE supply, were observed and found adequate. No deficiencies were cited during this inspection visit.

Licensing Program Analyst Don Senaha conducted a Case Management visit to check on the health and safety of the residents living at the facility.

A deficiency and civil penalty were assessed for fingerprint clearance violations involving two staff members who worked prior to obtaining required California clearances. The citation was cleared during the visit.

Unannounced complaint investigation conducted due to multiple allegations received on 11/15/2021 regarding resident care issues at Pepper Tree Assisted Living Facility.

The investigation found no substantiated evidence for the allegations including failure to reposition residents, timely diaper changes, bathing, pressure injury care, medication administration, and bedding changes. Hospice nurses provided continuous care for the resident in question, and facility staff assisted as needed.

The complaint included allegations that staff did not reposition residents, change diapers timely, bathe residents, administer medications, change bedding, and that a resident sustained a pressure injury while in care. All allegations were found unsubstantiated after interviews and record reviews.

An unannounced Plan of Correction (POC) case management visit was conducted to review and clear outstanding corrective actions at the facility.

The Licensing Program Analyst reviewed all medications for resident R1, including over-the-counter medications, and cleared the outstanding Plan of Correction. An exit interview was conducted with the House Manager.

An unannounced complaint investigation was conducted following a complaint received on 2021-11-15 regarding multiple allegations of inadequate care at Pepper Tree Assisted Living Facility.

The investigation found no preponderance of evidence to substantiate the allegations, which included failure to reposition residents, timely diaper changes, bathing, medication administration, and bedding changes. Hospice nurses were primarily responsible for care, and staff assisted as needed. All allegations were determined to be unsubstantiated.

The complaint involved allegations that staff did not reposition residents, change diapers timely, bathe residents, administer medications, or change bedding, and that a resident sustained a pressure injury while in care. The investigation concluded all allegations were unsubstantiated based on interviews and record reviews.

An unannounced required annual visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tools.

The facility was found to be clear of Covid-19 infection with adequate infection control practices, PPE supplies, and sanitation. One deficiency was cited related to medication labeling where over-the-counter medication bottles lacked prescription labels.