TICE VALLEY RESIDENTIAL CARE

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to the temperature of the resident's bathroom measured to 129.6 degrees Fahrenheitwhich poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2025 Plan of Correction Administrator will submit photo proof to LPA of a lowered max temperature on or before due date.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 for 3 of 5 residents missing the form LIC 602 and/or other pre-placement physical and psychological assessments, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/03/2024 Plan of Correction On or before due date, Licensee shall send proof to LPA that an appointment has been scheduled for the residents to have their pre-placement medical assessments and/or to add missing documentation including Consent Forms, Admission Agreements, and Statement of Valuables.

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 2 out of 6 employees, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/05/2023 Plan of Correction All current employees must have completed Health Report with TB testing on or before due 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 record review, the licensee did not comply with the section cited above in 5 out of 5 staff people do not have CPR training, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/05/2023 Plan of Correction All current employees must have completed CPR training on or before due date.

Official classification

Type B

Official code

87465(a)(8)(A)

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: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. 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 1 out of 1 first aid kits, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/05/2023 Plan of Correction Licensee shall obtain a complete first aid kit for the facility on or before the due date.

Official classification

Type B

Official code

87618(b)(3)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: 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 1 out of 1 residents using oxygen equipment, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/05/2023 Plan of Correction Licensee shall post signs and submit a written report to local fire jurisdiction that oxygen is in use at the facility.

Official classification

Type B

Official code

87705(h)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (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: Based on observation, the licensee did not comply with the section cited above in 1 out of 3 gates that was not self-closing, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

On or before due date, Licensee shall add self-closing mechanism to the gate without one.

Deadline recorded: Feb 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 CARE OF PERSONS WITH DEMENTIA (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. Based on observation by the LPA, the Licensee did not comply with the section cited above. No auditory device is on 1 out of 7 of the facility exits, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to install an auditory device and to provide picture proof to the LPA by the due date.

Deadline recorded: Oct 7, 2022. A deadline is not proof that correction was completed.

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... administrator . . . The administrator... shall be on the premises a sufficient number of hours.... The Department may require that the administrator devote additional hours in the facility... This requirement was not met as evidence by: Based on observation by the LPA, the Licensee did not comply with the section cited above. An Administrator has not been on premises a sufficient number of hours (20 per week minimum), which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to: (1) update LIC500 to reflect days and hours she will be present as Administrator at the facility. (2) Review Title 22 regulation 87405 " Administrator – Qualifications and Duties " . (3) Submit a self-certification that the regulation has been reviewed and administrator will abide by the regulation going forward. (4) Self-certification and updated LIC500 will be submitted by the POC date.

Deadline recorded: Oct 7, 2022. 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

87303 MAINTENANCE AND OPERATION (e) Water supplies . . . shall be maintained as follows: (2) Faucets used by residents . . . hot water . . . 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: Based on observation by the LPA, the Licensee did not comply with the section cited above. The hot water temperature was measured at 130 degrees, which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator agreed to: (1) Self-certify that the hot water temperature was between 105 and 120 degrees F. (2) Purchase a thermometer to accurately measure water temperature. (3) Create and train staff in updating a daily hot water temperature log going forward.

Deadline recorded: Oct 1, 2022. 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 with a hot water temperature of 138 degrees, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/20/2022 Plan of Correction Licensee shall reduce hot water temperature to the safe range of 105 to 120 degrees by the due date and attest to LPA that has been done.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. 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 Room #5, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2022 Plan of Correction Licensee shall repair screen and send proof to LPA by due date.

Official classification

Type B

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 in all refrigerators and freezers where food was stored without a date on it identifying the date it was opened, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2022 Plan of Correction Licensee shall date and securely close all foods stored in the refrigerators and the freezers.

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 because of the junk in the back yard on the ground, and because of the hazards created from the deteriorating physical plant that includes: rotted flooring and broken railings in the decking in ALL regions of the property, missing and ill-fitting gate latches, tripping hazards in the cement walkways, at least 6 doors inside and out that will not properly close, and at least 3 kitchen drawers coming apart, which pose a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/30/2021 Plan of Correction Provide proof in the form of pictures to LPA Sampair that all of the junk has been removed from the back yard and that the repairs inside and outside have been completed.