IVY PARK AT SAN LAUREN

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 in LPA observed water temperature measuring to be 122 degrees, and facility maintenance staff documented multiple resident rooms to measure above 120 degrees, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/22/2026 Plan of Correction Administrator will ensure facility maintenance staff audits and corrects resident bathroom water temperatures, and completes training with facility maintenance staff on water temperature being between 105 and 120 degrees, and submit to LPA by POC date of 06/22/2026.

Official classification

Type A

Official code

80078(a)

Regulation authority

CCR

What the official deficiency says

Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by R1 eloped out of her bedroom window and subsequently called her family to inform them she had 'gotten out'. R1 was immediately returned to the facility. Elopement poses an immediate risk to the health and safety of residents.

Official plan of correction

Facility has installed new locks on the resident bedroom windows and regarding R1 have arranged one on one care until further notice. Plan of correction will be cleared at today's visit.

Deadline recorded: Jun 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights 87468.1 (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by Shower equipment (hot water) was not available and functioning for several days and residents who were not informed of alternative had to do without taking a shower. This poses a potential risk to the health and safety of the residents in care.

Official plan of correction

The water issue was fixed under the prior administrative team. Showers and hot water are available and have been since repair was completed. The POC will be cleared as of today's visit.

Deadline recorded: May 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operations: (a) 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 was not met as evidenced by Hot water system was not functioning and resdients were without access to hot running water in their units. This poses a potential risk to the health, safety and personal rights of the resdients in care.

Official plan of correction

Facility has developed a memo draft that will be modified to accomodate any building issue that residents need to be aware of that will effect their daily living. Meetings will be documented and attendance noted, and information provided will be distributed to those not present. This will ensure that residents are made aware of pysical plant issues, what is being done to remedy the issue and what is being done to mitigate the impact. Updates will be provided as necessary as issues are remedied. Sample memo provided at today's visit. POC will be cleared at today's visit.

Deadline recorded: Feb 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)(3)

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. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement was not met as evidenced by: Administrator did not provide requested records for the dates of 3/15/23 to 03/31/23 for the signal system at the facilty which poses a potential health, safety and/or personal rights risk to residents in care.

Official plan of correction

Plan of Correction POC Administrator agrees to submit a written plan on how this regulation with be met in the future by POC due date of 06/20/23.

Deadline recorded: Jun 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

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:(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 was not met as evidenced by: Facility did not report emergency services responding for R1 which poses a potential health, safety and/or personal rights risk for residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to submit an understanding of this regulation and a plan in writing on how this regulation will be met by POC due date of 6/20/23.

Deadline recorded: Jun 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ... This requirement was not me evident by: Based on LPA's interviews and record reviews, on 3/29/2023, the Licensee did not ensure staff were present, for approximately 30 minutes, to respond to the facilities signall system, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to provide copies of the facility signal system, to the Department between the dates of 6/9/2023 through 6/15/2023, for review. Seven records are to be provided to the Department by POC due date of 6/16/2023.

Deadline recorded: Jun 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.49(c)(3)

Regulation authority

HSC

What the official deficiency says

1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:(3) Absence of supervision as required by statute or regulation. This regulation was not met as evidenced by: On 03/29/23 Facility did not have staff present in the faciltiy and did not provide care to R1 for at least 30 minutes which poses an immediate health, safety, and/or personnnel rights risks to residents in care.

Official plan of correction

Plan of Correction POC Facility agrees to submit a plan to have suffiecient staff and to train staff on emergency procedures for emergency leave by POC due date 06/9/23. Licensee will submit staff training by 6/30/23. Civil Penalty was issued.

Deadline recorded: Jun 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(a)(2)(A)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows:(2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated or visibly soiled. This requirement was not met as evidenced by LPA's interviews and observation of text messages, that included the time and date of a visibly soiled bathroom and floor in Resident R1's room. This poses a potential threat to residents in care.

Official plan of correction

Administrator will provide LPA with the cleaning checklist for each resident room in the Memory Care. Checklists will document and identify any immediate concerns to be corrected same day. Administrator will send proof of staff signatures evidencing rooms have been checked daily for the next 30 days. Proof of signed daily checklist will be sent to LPA by 06/25/23.

Deadline recorded: Jun 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87459(a)(6)(B)

Regulation authority

CCR

What the official deficiency says

87459 Functional Capabilities (a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to: (6) Eating, including the need for:(B) Assistance from another person. This requirement was not met as evidenced by LPAs observation of LIC602, evidencing a change of condition. A functional assessment for feeding was not documented as completed by facility. This poses a potential risk to residents in care.

Official plan of correction

Administrator will provide proof that care staff has been retrained on how to document resident's change of condition and reassessing resident needs after a change of condition occurs.

Deadline recorded: Jun 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements:(a) Each licensee shall furnish to the licensing agency…(1) A written report… within seven days of the occurrence of…(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on interviews, the facility did not submit an incident report for R1 when R1 became aggressive towards staff and other residents resulting in R1 being transported to the hospital, which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee will submit a written statement detailing steps the facility will take to ensure the requirements of section 87211 are met to the Fresno CCL office by the POC due date. Administrator agreed that staff will be trained on the requirements for section 87211 Reporting Requirement Regulations by 03/17/2022 and documentation of training topics and attendance will be submitted to the Fresno CCL office by 03/18/2022.

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