ROYAL CARE

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, interview record review, the licensee did not comply with the section cited above in 1 out of 1 fire drill was not conducted within the quarterly period. Date completed on 3/30/26 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2026 Plan of Correction LIcensee agrees to have staff conduct a fire drill and send copy of completed fire drill to CCLD by POC due date.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation resident 1 (R1) medication was checked and MARs was reviewed. Two out of six medications were not administered as directed by staff which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2024 Plan of Correction Licensee agrees to have all staff retrained in Medication training and submit written documentation upon completion of training. Proof of staff trainings and rooster of staff attendance will be submitted to the Fresno CCL by POC due date 08/31/24.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(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 when LPAs and Administrator observed knives unlock in kitchen drawer, cleaning chemicals unlock in laundry shelf and in garage cabinet accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2024 Plan of Correction Administrator immediately locked chemicals in hall closet and locked the knife drawer. Gardening tools was immediately removed out of the facility. POC cleared.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when LPAs and Administrator observed refrigerate medications stored unlocked in the small black refrigerator accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2024 Plan of Correction Administrator immediately removed medications to locked area. POC cleared during visit.

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 3 out of 3 areas; unlocked disinfecting spray, Dish soap observed under kitchen sink. Antiseptic Alcohol observed in unlocked cabinet above washing machines. Laundry detergent, bleach, and used syringes observed in unlocked garage which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2023 Plan of Correction Licnesee to remove items and place in locked area. License to ensure items remain locked in the future. Staff removed items and placed them in locked area during tour. POC cleared during visit.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. 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 3 out of 3 medication audit of three individuals that revealed medication that was noted given was not which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2023 Plan of Correction Licnesee to submit a Statement of intent to complete medication audit for all residents and provide in-service training to staff on correct administration of medication and documentation. Licnesee to ensure future spot checks to avoid medication issues.

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 1 out of 1 areas where LPA(s) observed unlocked backup medication in a cabinet in the office which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2023 Plan of Correction Licnesee to remove items and place in locked area. License to ensure items remain locked in the future.

Official classification

Type B

Official code

87303(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. 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; used insulin sharps are kept in emptied laundry detergent/softener container, but were not labeled as BIOHAZARDOUS WASTE or SHARPS WASTE. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2023 Plan of Correction Licnesee to utilize the Biohazard waste container observed in the garage or label the container used with correct signage.

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 3 out of 3 staff files; review showed no forms available at the facility for Licensee except for Administrator License which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Licensee to update all Staff files to reflect the necessary required documentation by due date.

Official classification

Type B

Official code

87217(g)(1)

Regulation authority

CCR

What the official deficiency says

87217 Safeguards for Resident Cash, Personal Property, and Valuables(g)(1): Records of residents' cash resources maintained as a drawing account shall include a ledger accounting (columns for income, disbursements and balance) for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current. This requirement was not met as evidenced by: Based on interviews and record review, Licensee did not maintain accurate records of cash resources for R1, which posess a potential health and safety risk to client in care.

Official plan of correction

Licensee agrees to submit a written statement detailing how the facility will maintain accurate records for cash resources and provide the last 6 months of bank statements and account ledgers for residents in care to the Fresno CCL office by 03/28/2022 Licensee agreed that staff will be trained on requirements of Safeguards for Resident Cash, Personal Property, and Valuables. Documentation of training topics and attendace will be submitted to the Fresno CCL office by 03/28/2022.

Deadline recorded: Mar 28, 2022. 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 when LPAs observed 1 bottle of Comet under under the laundry sink in the hallway accessible to residents in care, this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/15/2021 Plan of Correction The licensee immediately removed the bottle of Comet and placed it in secured cabinet during visit. POC cleared during inspection.