EMA BOARD AND CAREHOME

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 S2 and S3 not being first aid or CPR certified which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Administrator agreed to have S2 and S3 become first aid and CPR certified and submit certification to CCLD by POC date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 having staff conduct annual training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Administrator agreed to have staff conduct annual training and submit certifications and/or in-service sign-in sheets to CCLD by POC date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 having an updated appraisal needs and services plan for R1, R2, R3 and R5 which poses a potential health or safety risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Administrator agreed to prepare an appraisal needs and services plan for each resident and submit plans to CCLD by POC date.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(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 a supply of 7-day non perishables and 2-day perishable for residents which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Administrator agreed to purchase food and submit pictures and receipts to CCLD by POC date.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 smoke detectors and carbon monoxide detectors operable which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/30/2025 Plan of Correction Administrator agreed to replace smoke and carbon monoxide detectors and submit photos to CCLD by POC date.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(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 a chest of drawers, 2 wheelchairs, 2 bedrails, a recliner and a chair in passageway which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Administrator agreed to remove all items and submit photo to CCLD by POC date.

Official classification

Type B

Official code

87458(b)

Regulation authority

CCR

What the official deficiency says

(b) The licensee shall obtain an updated medical assessment when required by the Department. 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 having an updated medical assessment for R1, R2, R3, and R5 which poses a potential health or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Administrator agreed to have each of the residents and updated medical exam or date for exam and submit copy to CCLD by POC date.

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 observation and record review, the licensee did not comply with the section cited above in having S4 personnel file complete which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2024 Plan of Correction Administrator agreed to have S4 obtain a health screen including TB, complete a LIC501, and submit documents to CCLD by POC date.

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 keeping mice droppings out of kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2024 Plan of Correction Administrator agreed to submit two (2) current invoices for exterminator service or hire an exterminator and submit invoice to CCLD by POC date.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: 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 having a hospice care plan for R1 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2024 Plan of Correction Administrator agreed to obtain a hospice care plan for R1 and submit to CCLD by POC date.

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in having working smoke detectors and fire extinguisher serviced which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2024 Plan of Correction Administrator agreed to have fire extinguisher serviced and install smoke detectors and submit photos to CCLD by POC date.

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 in having medications in refrigerator inaccessible which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/30/2024 Plan of Correction Administrator agreed to put medications that are in the refrigerator in a locked box and submit photo 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 observation and record review, the licensee did not comply with the section cited above in conducting a quarterly fire drill which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2024 Plan of Correction Administrator agreed to conduct a fire drill and submit form to CCLD by POC date.

Official classification

Type B

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited aboved in reporting an incident to CCLD which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to sumbit and LIC624 (incident report to CCLD by POC date.

Deadline recorded: Jan 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87632(d)(2)

Regulation authority

CCR

What the official deficiency says

87632 (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver... (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in notifying CCLD by subimtting a hospice notification which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to review regulation 87632 and submit self-certification that the regulation has been reviewed and will be abided by going forward to CCLD by POC date.

Deadline recorded: Jan 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 scissors, knives, detergents and disinfectants accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2023 Plan of Correction Administrator agreed to lock away all items and submit photo to CCLD by POC date.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation an record review, the licensee did not comply with the section cited above in having all staff with first aid and/or CPR which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/08/2023 Plan of Correction Administrator agreed to get all staff first aid certified and submit certificates to CCLD by POC date.

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 observation and record review, the licensee did not comply with the section cited above in having a completed file for S3 available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/08/2023 Plan of Correction Administrator agreed to complete a file for S3 and submit self-certification that the file has been completed to CCLD by POC date.

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 observation and record review, the licensee did not comply with the section cited above in having a current appraisal needs and services plan for all residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/08/2023 Plan of Correction Administrator agreed to submit self-certification that a current appraisal needs and services plan has been created for each resident and submit a self-certification to CCLD by POC date.

Official classification

Type B

Official code

87609(b)(4)

Regulation authority

CCR

What the official deficiency says

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). 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 having an agreement with the home health agency for review for R1 and R6 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/08/2023 Plan of Correction Administrator agreed to obtain an agreement or care plan from the home health for R1 and R6 and submit plan to CCLD by POC date.

Official classification

Type B

Official code

87618(b)(3)(E)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. 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 oxygen tanks secured to the wall or on a stand which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/08/2023 Plan of Correction Administrator agreed to place oxygen tanks on a stand or secure them to the wall and submit photo to CCLD by POC date.

Official classification

Type B

Official code

87307(a)(2)(C)

Regulation authority

CCR

What the official deficiency says

(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: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in using the bedroom as a passageway to the bathroom for staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/08/2023 Plan of Correction Administrator agreed to submit self-certification that staff will not use bedroom as a passageway to the bathroom, and that the bathroom can be used by the residents, to CCLD by POC date.

Official classification

Type B

Official code

87555(26)

Regulation authority

CCR

What the official deficiency says

(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 having 7-day non perishable and 2-day perishable food for residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/08/2023 Plan of Correction Administrator agreed to purchase food and submit photos and receipts to CCLD by POC date.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. 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 reporting R1 and R6 hospitalization which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/08/2023 Plan of Correction Administrator agreed to submit LIC624 for R1 and R6 to CCLD by POC date.

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or 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 having S3 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2022 Plan of Correction Licensee agreed to associate R1 to the facility and submit copy of association to CCLD by POC date.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 knives inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2022 Plan of Correction Caregiver locked knives in locked kitchen pantry during visit. Deficiency cleared during visit.

Official classification

Type B

Official code

87555(b)(32)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (32) Equipment or appropriate size and type shall be provided for the storage, preparation and service of food and for sanitizing utensils and tableware, and shall be well maintained. 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 an operable refrigerator in kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2022 Plan of Correction Licensee agreed to place a working refrigerator in kitchen and submit a photo 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 having a 7-day non-perishable and 2-days perishables food available for residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2022 Plan of Correction Licensee agreed to purchase food and submit photo copies of food and receipts to CCLD by POC date.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a certified Administrator employed at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2022 Plan of Correction Licensee agreed implement a plan to hire an Administrator or recertify as the Administrator, and submit plan to CCLD by POC date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (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 observation, interview, and record review, the licensee did not comply with the section cited above in having S2 first aid certified which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2022 Plan of Correction Licensee agreed to have S2 recertified for first aid and submit photo copy to CCLD by POC date.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (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. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review), the licensee did not comply with the section cited above in having doctor orders for R1 and R2 hospital beds which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2022 Plan of Correction Licensee agreed to obtain doctor's orders for R1 and R2 hospital beds and submit a photo copy to CCLD by POC date.