AGEWAY BOARDING CARE #3

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 by having front window screen in disrepaired, and RM 1 closet door is in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/11/2026 Plan of Correction Licensee agree to fix front window screen and RM 1 closet. Licensee will submit photo 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. LPA observed medication, cream left on kitchen counter, prescribed eye drops inside refrigerator, and inside resident’s room/ bathroom, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2025 Plan of Correction Administrator agree to lock up all knives, and conduct in service training to all staff and submit photo of all lock knives to CCLD by POC date.

Official classification

Type A

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above. LPA observed two mold eggplant inside the refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2025 Plan of Correction Administrator agree to check and throw away all mold items that is in the refrigerator and conduct in service training to all staff and submit photo to CCLD by POC date.

Official classification

Type A

Official code

1569.695(a)(7)(E)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (E) Storage and preservation of medications, including the storage of medications that require refrigeration. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed medication, cream left on kitchen counter, prescribed eye drops inside refrigerator, and inside resident’s room/ bathroom, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2025 Plan of Correction Administrator agree to check and medication, cream left on kitchen counter, prescribed eye drops inside refrigerator, and inside resident’s room/ bathroom. conduct in service training to all staff and submit photo to CCLD by POC date.

Official classification

Type B

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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. LPA reviewed files 3 bedridden but facility did not get fire clearance which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Administrator will submit proof of fire clearance for 3 bedridden to CCLD by POC date.

Official classification

Type B

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons 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. LPA reviewed files there are record of fire marshal of the bedridden resident, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2025 Plan of Correction Administrator will notify fire marshal of the number of bedridden facility currently have and submit communication record to CCLD by POC date.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed the side gate can only open half was and the floor concert lift from the ground, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/23/2025 Plan of Correction Administrator will repair and fix the side gate can only open half was and the floor concert lift from the ground submit photo to CCLD by POC date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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. LPA file reviewed shows R1 without TB result, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2025 Plan of Correction Administrator submit R1 TB clearance to CCLD by POC date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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. LPA reviewed files no update fire drill conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Administrator conduct fire drill and submit proof to CCLD by POC date.

Official classification

Type B

Official code

87606(c)

Regulation authority

CCR

What the official deficiency says

(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance. 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. LPA reviewed files 3 bedridden but facility did not get fire clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/16/2025 Plan of Correction Administrator obtain fire clearance for 3 bedridden and submit proof to CCLD by POC date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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. LPA reviewed files R4 did not have a doctor order for bedrail, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Administrator will obtain doctor order for bedrail for R4 and submit proof to CCLD by POC date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

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 hot water measuring at 126.7 F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction Hot water was adjusted to 109 F during the visit. This deficiency is cleared.

Official classification

Type B

Official code

87705(h)

Regulation authority

CCR

What the official deficiency says

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Facility failed to maintain backyard fence which poses/posed a potential health, safety or personal rights risk to persons in care. Several wood planks were observed down on the ground.

Official plan of correction

POC Due Date: 04/14/2023 Plan of Correction By POC date, Administrator will get the fence fixed and submit to CCL photo as proof.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate…. This requirement is not met as evidenced by… Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t reappraise resident when resident have pressure ulcers multiple times which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to review and understand regulation and submit a self-certification of being in compliance in future events to CCL by the POC due date.

Deadline recorded: Feb 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(b)(13)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (13) Continuing record of any illness, injury....impacts the resident's ability to function or needed services. This requirement is not met as evidenced by… Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t have care note for resident who have health condition change which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to review and understand regulation, retrain staff for note taking, and submit in-service training with staff signatures to CCL by the POC due date.

Deadline recorded: Feb 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal - General(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed..... This requirement is not met as evidenced by… Based on record review, the licensee did not comply with the section cited above. LPA observed resident R1's pre-admission appraisal was not completed while admitting to facility on 3/1/22, which poses a potential health and safety concern to persons in care.

Official plan of correction

Administrator agrees to submit a copy of completed appraisal form (LIC603) to CCL by the POC due day.

Deadline recorded: Oct 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. 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 monitoring bedroom #1 with a video monitor which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/12/2022 Plan of Correction Caregivers immediately unplugged and removed baby monitors from bedroom #1 for family to pick up. Deficiency cleared during visit.