FOOTHILL COTTAGE

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 one out of two staff files were missing a health assessment, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2025 Plan of Correction Licensee/Administrator agrees to have staff obtain a heath assessment and provide proof of the completed assessment to licensing by end of business on August 19, 2025.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis … This requirement has not been met as evidenced per the department's investigation which substantiated that R1 did not receive timely medical care.

Official plan of correction

Licensee shall update and submit the facilities emergency response policy and training plan for all direct-care staff. Updated Policy shall be submitted by end of business on 06/17/24.

Deadline recorded: Jun 17, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 that chemicals were found to be stored under a bathroom sink unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2024 Plan of Correction The administrator will provide a training to the staff of the importance of storing chemicals inaccessible to residents. Administrator will inform the LPA when the training is completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis … This requirement has not been met as evidenced by the incident report submitted to the Department which describes the events of the incident and articulates that R1 did not receive medical treatment for over 24 hours for an fall resulting in injury that they had at the facility.

Official plan of correction

Licensee will submit a copy of the emergency response policy as well as a plan to provide training with all employees prior to their work in the home. The POC is due by 06/17/24. Policy, training plan and 7 day schedule to be submitted.

Deadline recorded: Jun 10, 2024. A deadline is not proof that correction was completed.

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 interview and review of files, the licensee did not comply with the section cited above an emergency disaster drill log was not produced which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/18/2023 Plan of Correction By 8/18/2023 licensee shall conduct emergency disaster drills and keep a log of emergency disaster drills. Licensee shall create a plan to ensure that emergency disaster drills are completed and documented quarterly as required per regulations.

Official classification

Type A

Official code

87616

Regulation authority

CCR

What the official deficiency says

87616(a)(b)(1)(2)(3) Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. (b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. (2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility. (3) Plan for minimizing the impact on other residents. This requirement is not met as evidenced by: Based on the department investigation the facility failed to submit a written exception for the resident’s stage IV pressure sore in a timely manner. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees to provide CCLD with a plan for preventing Stage III, IV or unstageable wounds from developing, and if they should develop what the plan is for relocation or exception request. Violations that result in the injury of a client in care are subject to an immediate civil penalty of $500 per violation followed by $100 per day until the deficiency is corrected. Civil penalty assessed at $500. The proof of correction is to be received by LPA Knight by 02/14/2023.

Deadline recorded: Feb 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as … physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on the department investigation it was determined that the licensee failed to observe changes in R1's condition and follow the home health plan of care. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees to provide training for all direct care and administrative staff in the proper observation of residents. The training will be conducted by a STATE APPROVED VENDOR. Licensee will schedule the training and provide CCL with the date of the scheduled training and contact information for the trainer as the POC. The proof of correction is to be received by LPA Knight by 02/14/2023.

Deadline recorded: Feb 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87609

Regulation authority

CCR

What the official deficiency says

87609(b)(2) Allowable Health Conditions and the Use of Home Health Agencies – (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (2) The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care. This requirement is not met as evidenced by: Based on the department investigation the facility failed to follow the treatment plan as prescribed for resident which resulted in the resident sustaining a stage 4 pressure injury while in care. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to provide training for all direct care and administrative staff in the requirement to follow a treatment plan as prescribed for resident who is receiving home health care. The training will be conducted by a STATE APPROVED VENDOR. Licensee will schedule the training and provide CCL with the date of the scheduled training and contact information for the trainer as the POC. The proof of correction is to be received by LPA Knight by 02/14/2023.

Deadline recorded: Feb 14, 2023. A deadline is not proof that correction was completed.