BETHANY HOME

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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 by having unlocked medications in a kitchen drawer which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2025 Plan of Correction Staff locked up the medications in a lockbox during inspection. Deficiency cleared.

Official classification

Type A

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. 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 staff records at the facility ] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2023 Plan of Correction The facility agrees have completed staff records at the facility for each staff member. Proof of correction will be sent to CCLD by POC date.

Official classification

Type A

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 record review, the licensee did not comply with the section cited above by having the resident records in part at the facility and in part on a computer that comes and goes with the manager which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2023 Plan of Correction The facility agrees to have printed copies of all resident records separated at the facility. Proof of correction will be sent to CCLD by POC date. $1000 Civil Penalty is being assessed for repeat violation

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 the toilet in room three dirty and broken which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/17/2023 Plan of Correction The facility agrees to clean and repair the toilet in room 3. Proof of correction will be sent to CCLD by POC date.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation) add interview, the licensee did not comply with the section cited above by not having the PUB 475 posted in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/17/2023 Plan of Correction The facility agrees to post the PUB 475 in the 20” x 26” in size. Proof of correction will be sent to CCLD by POC date.

Official classification

Type B

Official code

87705(c)(4)(A)

Regulation authority

CCR

What the official deficiency says

Licensees who accept and retain residents with dementia...Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty... This requirement is not met as evidenced by: The facility having a resident AWOL, and the staff were not awake when the police arrived to assist in returning her to the facility.

Official plan of correction

Licensee shall complete an LIC500, verifying facility is adequately staffed at all times. Licensee shall submit to licensing, a copy of current LIC500 by POC date.

Deadline recorded: Oct 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

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: Based on observation and record review, Licensee did not comply with the regulations cited above by not having 4 out of 6 resident records at the facility

Official plan of correction

Administrator agreed to put together and complete files for all residents and submit a copy of all documentation to CCLD by POC

Deadline recorded: Aug 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(a)(1)

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 the chemical under the kitchen sink left unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/29/2022 Plan of Correction POC was cleared during the visit