BLUEGARDEN CARE

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 in having cleaners and knives unlocked which posed an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2026 Plan of Correction Staff secured dangerous items POC clear

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 centerally stored medications being unlocked which posed an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2026 Plan of Correction Staff locked and secured medications POC clear

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed 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 in having uncleared person residing at facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2024 Plan of Correction Individual left during visit

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 an unlocked knife being in kitchen which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2024 Plan of Correction Caregiver removed knife

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 record review, the licensee did not comply with the section cited above in S3 not having a tb result on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2024 Plan of Correction By POC date Administrator agrees to get a TB result for employee and submit copy to CCLD

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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 not having any file available for S3 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2024 Plan of Correction By POC date Administrator agrees to make a file for S3 and self certify to CCLD.

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 record review, the licensee did not comply with the section cited above in not maintaing staff files with the nessesary information which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2024 Plan of Correction By POC date Administrator agrees to complete all staff files and notify CCLD

Official classification

Type B

Official code

87406(a)

Regulation authority

CCR

What the official deficiency says

(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. 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 not having a valid administrators certificate which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2024 Plan of Correction By POC date Administrator agrees to submit documents for certificate renewal and notify CCLD

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 in S3 not being certified which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2024 Plan of Correction By POC date Administrator agrees to have S3 certified and submit certificate to CCLD

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 innot doing the required quarterly drill which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2024 Plan of Correction By POC date Administrator agrees to conduct a drill and submit photographic proof of the drill in progress to CCLD

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 record review, the licensee did not comply with the section cited above ina resident having an incomplete file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2024 Plan of Correction By POC date Administrator agrees to update file and notify CCLD

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 record review, the licensee did not comply with the section cited above. A pair of scissors was in unlocked drawer in kitchen, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2023 Plan of Correction Licensee cleared violation during visit.

Official classification

Type B

Official code

1569.618(c)

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: 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, because 0 of 2 staff members who are on duty have cardiopulmonary resuscitation (CPR) training or first aid training, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2023 Plan of Correction Staff members shall complete their training in CPR and first aid. Licensee shall inform LPA that they have completed their training.

Official classification

Type B

Official code

87415(a)

Regulation authority

CCR

What the official deficiency says

(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: 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, because 0 of 2 staff members who are on duty have cardiopulmonary resuscitation (CPR) training or first aid training, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2023 Plan of Correction Staff members shall complete their training in CPR and first aid. Licensee shall inform LPA that they have completed their training.

Official classification

Type B

Official code

87507(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, because no Admission Agreement is posted at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2023 Plan of Correction Licensee shall post copy of Admission Agreement. Licensee shall inform LPA when posted.

Official classification

Type B

Official code

87508(b)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: 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, because she has no register of current residents, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2023 Plan of Correction Licensee shall create current register of all residents in the facility. Licensee shall inform LPA when register created.

Official classification

Type B

Official code

87465(a)(8)

Regulation authority

CCR

What the official deficiency says

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, because there is not a current first aid kit at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2023 Plan of Correction Cleared during inspection.

Official classification

Type B

Official code

87507(e)

Regulation authority

CCR

What the official deficiency says

Admission Agreements. The licensee shall provide a copy of the signed ...admission agreement ...immediately upon signing the admission agreement... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not providing a copy of the admission agreement to resident which poses a potential health and safety risk to the persons in care.

Official plan of correction

Administrator has agreed to provide a copy of the admission agreement to resident and review regulation regarding admission agreement. Administrator will submit self-certification by POC date.

Deadline recorded: Nov 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. The hot water in kitchen measured at 128.7 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2023 Plan of Correction Licensee shall send picture proof and/or attest to decreasing temperature to 105 to 120 degrees Fahrenheit.

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 the kitchen and in the main bathroom where cleaning solution was stored in unlocked kitchen and bathroom cabinets, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2023 Plan of Correction Licensee shall attest to LPA that the cleaners have been moved to a location inaccessible to residents.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: 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. There is no plan of operation at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall send a copy of the facility's plan of operation to the LPA.

Official classification

Type B

Official code

87208(a)(12)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. 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. There is no infection control plan at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall send a copy of the facility's infection control plan to the LPA.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. 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 the main bathroom that has no toilet paper holder, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall have a toilet paper holder installed in the main bathroom and send picture proof to LPA.

Official classification

Type B

Official code

87307(d)(5)

Regulation authority

CCR

What the official deficiency says

(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. There are no nightlights in the facility's hallways, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall have night lights installed in the hallways and send picture proof to LPA.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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. There were no personnel records available at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall get copies of all staff records to the facility and notify LPA when they are at the facility.

Official classification

Type B

Official code

87412(a)(13)(B)

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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. 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. No administrator records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall get copies of all administrator records to the facility and notify LPA when they are at the facility.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. 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. No training records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall create a training plan and/or train and/or enroll all staff in the required courses for them to complete this requirement and inform LPA with proof that this has been completed.

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 record review, the licensee did not comply with the section cited above. No training records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall create a training plan and/or train and/or enroll all staff in the required courses for them to complete this requirement and inform LPA with proof that this has been completed.

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. No training records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall create a training plan and/or train and/or enroll all staff in the required courses for them to complete this requirement and inform LPA with proof that this has been completed.

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 record review, the licensee did not comply with the section cited above. No training records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall create a training plan and/or train and/or enroll all staff in the required courses for them to complete this requirement and inform LPA with proof that this has been completed.

Official classification

Type B

Official code

1569.69(a)(4)(A)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (A) The role, responsibilities, and limitations of staff who assist residents with the self-administration of medication, including tasks limited to licensed medical professionals. 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. No training records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall create a training plan and/or train and/or enroll all staff in the required courses for them to complete this requirement and inform LPA with proof that this has been completed.

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 record review, the licensee did not comply with the section cited above. No complete resident records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall create complete records for each resident of the facility and notify LPA when they are at the facility.

Official classification

Type B

Official code

87456(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: 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. No complete resident records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall create complete records for each resident of the facility and notify LPA when they are at the facility.

Official classification

Type B

Official code

1569.695(a)

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: 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. No emergency and disaster plan for the facility was in use or at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall create an accurate and up-to-date emergency and disaster plan for the facility and send copy to LPA when it has been completed.

Official classification

Type B

Official code

1569.695(a)(2)

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: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. An emergency supply of water or food for 72 hours immediately following an emergency or disaster does not exist at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall obtain and store an adequate supply of food and water for 72 hours immediately following an emergency or disaster and provide picture proof that it is located at the facility.

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. No emergency drill record exists at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee shall create a binder to record the quarterly emergency and disaster drills, conduct the first one of 2023 for every staff member, and record the results in the binder. Licensee shall send LPA copy when it has been completed.

Official classification

Type B

Official code

1569.695(e)(1)

Regulation authority

HSC

What the official deficiency says

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident. 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. No resident roster existed, which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Licensee corrected during visit.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: 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 2 out of 3 caregivers, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2023 Plan of Correction Caregivers left facility during inspection and cleared deficiency.

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. LPAs observed cleaning supplies cabinet in garage was unlocked which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/21/2022 Plan of Correction Deficiency cleared during visit. LPAs observed Administrator locked cleaning supplies cabinet. In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signature to CCLD by 5/27/2022.

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. LPAs observed unlocked medication inside kitchen drawer which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/21/2022 Plan of Correction Deficiency cleared during visit. LPAs observed Administrator locked knives away. In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signature to CCLD by 5/27/2022.

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. LPAs observed unlocked knives inside kitchen cabinet which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/21/2022 Plan of Correction Deficiency cleared during visit. LPAs observed Administrator locked knives away. In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signature to CCLD by 5/27/2022.

Official classification

Type A

Official code

87309(b)

Regulation authority

CCR

What the official deficiency says

87309 STORAGE SPACE (b) Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPAs observed disinfectant and cleaning supply stored inside centrally stored medication closet which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/21/2022 Plan of Correction Deficiency cleared during visit. LPAs observed Administrator removed items and locked it away. In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signature to CCLD by 5/27/2022.

Official classification

Type B

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. LPAs were unable to review staff records because records are not being maintained at facility which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/24/2022 Plan of Correction Administrator will review regulation and maintain personnel records at facility. Administrator will submit self-certification letter to CCL by POC date.

Official classification

Type B

Official code

87465(d)(2)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPAs observed visitors are not being properly screened and staff are not wearing masks which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/25/2022 Plan of Correction Administrator will review local county health order and Providers Information Notification from CCLD website. Administrator will implement guidance and submit self-certification letter to CCL.