FREMONT RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMON

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not having 7 of R2’s medication not available in the facility which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/13/2026 Plan of Correction By POC date, Executive Director agrees to obtain either a discontinued order for the medication and/or obtain the medication to have it readily available in the facility. Proof of correction will be sent to CCLD by POC date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having unlocked medications such as MiraLAX, Hydrocortisone Cream, and eye drops in R2’s room and unlocked chemicals such as Lysol, Comet, Kaboom Oxi Clean, etc. in R6’s room which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 02/27/2026 Plan of Correction The Executive Director agrees to lock the items and send proof to CCLD by POC date.

Official classification

Type B

Official code

87411(c)(6)

Regulation authority

CCR

What the official deficiency says

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement is not met as evidenced by: Deficient Practice Statement Based on a review of the records, the licensee did not comply with the section cited above by not having training documentation for all staff which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/07/2025 Plan of Correction Moving forward, Senior Executive Director agrees to have documentation for staff. Senior Executive Director agrees to self certify the regulation and send proof to CCLD by POC date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 by not having First Aid Certification for S2 to S5 which posses potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/11/2025 Plan of Correction Senior Executive Director agrees to have obtain First Aid Certification for staff and send proof to CCLD by POC date.

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

Limitations - Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons... This requirement is not met as evidence by: Based on observation and record review, licensee did not comply with the section cited above by having over capacity in number of residents which poses an immediate health and safety risk to the persons in care.

Official plan of correction

Executive Director has agreed to create a plan to address the over capacity issue and submit the written plan to CCLD by POC date. Civil penalty of $500 is being assessed.

Deadline recorded: Nov 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 by having incomplete staff files which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/05/2024 Plan of Correction Administrator agreed to complete staff files and email a sample and check list to CCL by POC.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 by having incomplete staff files which poses a potential health and safety rights to persons in care.

Official plan of correction

POC Due Date: 03/05/2024 Plan of Correction Administrator agreed to complete resident file and email a check list and sample file to CCL by POC date.