JOY SENIOR CENTER

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs… This requirement was not met as evidenced by staff failing to provide adequate care & supervision which posed an immediate health & safety risk to residents in care.

Official plan of correction

By POC due date, administrator agreed to complete and submit in-service staff retraining certifications by an approved CCL vendor on personal rights of residents in compliance with Section 87468.2 (a)(4). Immediate civil penalty of $500 assessed during visit for serious bodily injury. Additional civil penalty determination pending relating to serious bodily injury.

Deadline recorded: Apr 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above by having bedframes blocking the emergency exit passageway from the back door which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The facility agrees to remove the bedframes from the passageway. Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Jun 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having non skid mats in shared bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2024 Plan of Correction Administrator agreed to purchase non skid mats and submit photo to CCLD by POC date.

Official classification

Type B

Official code

87307(3)(C)

Regulation authority

CCR

What the official deficiency says

3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in [having beds without mattress pads, top sheets, and blankets which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2024 Plan of Correction Administrator agreed to place required linens on bed and submit self-certification that it has been completed to CCLD by POC date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in [having medication inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/30/2024 Plan of Correction Caregiver immediately locked medication cabinet. Deficiency cleared during visit.

Official classification

Type B

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in [using resident's bedroom to go to storage room which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2024 Plan of Correction Administrator agreed to move facility items out of storage in resident's bedroom and submit photo to CCLD by POC date.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: 6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on (observation, the licensee did not comply with the section cited above in having indoor and outdoor passageways free of obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2024 Plan of Correction Administrator agreed to remove all items and submit photos to CCLD by POC date.

Official classification

Type B

Official code

87555(B)(26)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in not having 7-day non perishables and 2-day perishables available for residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2024 Plan of Correction Administrator agreed to purchase food and submit receipts and pictures of food to CCLD by POC date.

Official classification

Type B

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in the medication administrative record accurate which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2024 Plan of Correction Administrator agreed to submit self-certification that the MAR will be accurate for all residents going forward to CCLD by POC date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above in having refrigerator in sanitary condition which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2024 Plan of Correction Administrator agreed to clean refrigerator and submit photo to CCLD by POC date.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential… or sexual abuse. This requirement is not met as evidenced by: S1’s actions of abusing R1’s cash resources. S1 used R1’s debit card to make personal purchases in the amount of $31,727.10.

Official plan of correction

A mandatory meeting will be held at a later date.

Deadline recorded: Aug 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.655(a)

Regulation authority

HSC

What the official deficiency says

If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice... This requirement is not met as evidenced by: The Licensee gave R1 a rate increase notice on 12/1/22 effective 1/1/23.

Official plan of correction

A mandatory meeting will be held at a later date.

Deadline recorded: Aug 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(d)

Regulation authority

HSC

What the official deficiency says

Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: The facility not having accurate logs of the resident’s ingoing and outgoing activities.

Official plan of correction

A mandatory meeting will be held at a later date.

Deadline recorded: Aug 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)(3)

Regulation authority

CCR

What the official deficiency says

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... (3) Ability to maintain or supervise the maintenance of financial and other records.This requirement is not met as evidenced by: Based on record review and interviews by the Department's Auditor, Licensee did not comply with the above regulation by mishandling R1's finances which poses a personal rights issue to residents in care.

Official plan of correction

A mandatory meeting will be held at a later date.

Deadline recorded: Aug 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87205(a)

Regulation authority

CCR

What the official deficiency says

The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement is not met as evidenced by: Based on record review by the Department's Auditor, Licensee did not comply with the above regulation by having knowledge of the staffs intents back in 2018 and still allowed S1 to work with R1.

Official plan of correction

A mandatory meeting will be held at a later date.

Deadline recorded: Aug 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff… This requirement is not met as evidenced by: R1’s medical assessment dated 12/3/2022 stated R1 had dementia and was unable to manage his own cash resources. Administrator possessed R1’s debit card but did'nt keep any records of purchases made. Licensee failed to protect R1’s from financial abuse from S1.

Official plan of correction

A mandatory meeting will be held at a later date.

Deadline recorded: Aug 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(9)

Regulation authority

CCR

What the official deficiency says

... a complete first aid kit shall be maintained and be readily available in a specific location in the facility. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

The licensee shall: (1) label the cabinet as " First Aid " , (2) ensure that within it is a kit that contains at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. (B) Sterile first aid dressings. (C) Bandages or roller bandages. (D) Scissors. (E) Tweezers. (F) Thermometers.

Deadline recorded: Jul 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on record reviEW, the licensee did not comply with the section cited above in Administrator failed to associate S4's fingerprint clearance which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2023 Plan of Correction Cleared and corrected

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in administrator failed to update needs and services plan to R2 and R5 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/10/2023 Plan of Correction Administrator agreed to update R2 and R5's needs and services plan. A copy of new needs and service plan needs to be submitted to CCL by POC date.

Official classification

Type B

Official code

87608(a)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in Administrator failed to update physician's report for R2 and R5 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2023 Plan of Correction Administrator agreed to update R2 and R5's LIC602 by poc date.