ST. CATHERINE'S HOME CARE, INC.

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 that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met by: Deficient Practice Statement Based on observation, R1, R2, and R3’s PRN medications were observed stored in the refrigerator bottom drawer unlock accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Staff immediately locked the PRN medications. POC cleared during visit.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record. This requirement was not met as evidenced by: Deficient Practice Statement Based on interview conducted, observations, and records reviewed, R2’s medication Nitrofurantoin Mono-MCR observed with 7 capsules left in bubble pack not recorded in the resident’s MAR, which poses an immediate health and safety risk for the person in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Licensee recorded medication Nitrofurantoin in R2’s MAR during visit. POC cleared during visit.

Official classification

Type A

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411(c)(1) Staff providing care shall receive appropriate training in first aid… This requirement is not met as evidenced by: Deficient Practice Statement Based on interview conducted and records reviewed, S1’s files was reviewed and did not have current First Aid training on file, this poses an immediate health and safety risk for the residents in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Licensee shall ensure that all staff have current First Aid training. Proof First Aid training for S1 is to be submitted to the Fresno CCL by 04/08/26.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(2) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview conducted with Licensee, the licensee did not comply with the section cited above when video cameras with audio was observed installed in the kitchen and front livingroom which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Licensee immediately removed the video cameras with audio camera. POC cleared during visit.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 when LPA reviewed R1, R2 and R3 who are currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Licensee obtain full rail order for hospice during visit. POC cleared during visit.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

87633(b) A current and complete hospice care plan shall be maintained in the facility for each hospice 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 when LPA reviewed R2 and R3 who are currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Licensee obtain current hospice care plan for R2 and R3 from hospice during visit. Licensee will obtain R1’s current hospice care plan and submitted to Fresno CCL by POC due date 04/10/26.

Official classification

Type B

Official code

87506(b)(17)

Regulation authority

CCR

What the official deficiency says

87506 (b)(17) Documents and information required… This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, residents’ files were reviewed and observed R1 do not have an appraisal (Lic 603), Needs and services plan (Lic 625), ID and Emergency Information (Lic 601), and Medical Consent form (Lic 627C) on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction Licensee shall ensure that all residents have the required records on file. R1’s Lic 601, Lic 603, Lic 625, and Lic 627C will obtained by POC due date and submitted the Fresno CCL office by POC due date 04/17/26.

Official classification

Type B

Official code

1569.185(e)

Regulation authority

HSC

What the official deficiency says

HSC 1569.185(e) Fees for license or applications; use of revenues; collected; denial or forfeiture. The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met by: Deficient Practice Statement Facility has overdue Annuals and Late Fees.

Official plan of correction

POC Due Date: 04/20/2026 Plan of Correction Licensee to bring account current prior to due date 04/20/26.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

87412(a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, Licensee/ Administrator and S2 do not have all the required personnel records maintained on file, which poses a potential health or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction Licensee shall ensure all staff have all the required records on file. Licensee will submit S2’s Lic 501, Lic 503, TB results, and Licensee/Administrator’s Lic 501 to the Fresno CCL office by POC due date 04/17/26.

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 LPA arrived and observed alcohol spray bottle on kitchen counter unlock 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: 05/16/2025 Plan of Correction Staff immediately removed and locked the alcohol bottle. POC cleared during visit

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state, and local authorities. Good in damaged containers shall not be accepted, used, or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, expired perishable and expired canned foods were observed, poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/16/2025 Plan of Correction Licensee immediately disregarded expired food. POC cleared during visit.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Deficient Practice Statement Based on observation, records reviewed, and interview conducted, R1’s medication Quetiapine 25mg was administered daily. Medication was checked LPA and Licensee and observed not administered as directed by physician, which poses/posed an immediate health and safety risk for the person in care.

Official plan of correction

POC Due Date: 05/16/2025 Plan of Correction Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 05/16/25.

Official classification

Type B

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87465 (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview conducted and observation, LPA and Licensee observed S1 taking R1’s refusal medications tablet and placing it in S1’s pocket, poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

POC Due Date: 05/21/2025 Plan of Correction Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 05/21/25. S1 shall be retrained on process of destroy medications and documentations of medication refusal. Training materials and staff attendance rooster will be submitted to Fresno CCL by POC due date 05/21/25.

Official classification

Type B

Official code

1796.45

Regulation authority

HSC

What the official deficiency says

Health and Safety Code 1796.45 TB Testing (a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and interview conducted, S2 completed TB testing on 08/02/2019, which poses a potential risk to the health and safety of the residents.

Official plan of correction

POC Due Date: 06/04/2025 Plan of Correction Licensee shall ensure all staff TB testing are exam no longer than 90 days prior hired date. S2 TB result shall be submitted to the Fresno CCL office by POC due date 06/04/25.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 (a)(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 interview conducted, observation, and records reviewed, R1, R2, and R3 uses half bed rail on hospital bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

POC Due Date: 05/21/2025 Plan of Correction Licensee shall obtain doctor orders for R1, R2, and R3 indicating the need for half bed rail and if physician do not indicate the need for half bed rail, hail rail must be removed by POC due date 05/21/25.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705(f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when medications were observed stored on kitchen counter and in resident’s dresser unlock accessible to residents. Cleaning chemicals were observed stored under kitchen sink unlock accessible to residents this poses an immediately health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/23/2024 Plan of Correction Licensee immediately removed medications and cleaning chemicals into lock shelf.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Deficient Practice Statement Based on interviews and records review, the licensee did not ensure staff administer medication to resident as prescribed by physicians, which poses an immediate health and safety risks to persons in care.

Official plan of correction

POC Due Date: 05/23/2024 Plan of Correction All staff in-service trainings on medication shall be completed by the POC due date. Copies of trainings and rooster of all staff attendance will be submitted to department by 05/23/24.

Official classification

Type B

Official code

1503.2

Regulation authority

HSC

What the official deficiency says

Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement was not met as evidenced by: Deficient Practice Statement Based on interviews and observation, facility does not have a carbon monoxide detector which poses a potential health and safety risks to persons in care.

Official plan of correction

POC Due Date: 05/27/2024 Plan of Correction Licensee shall ensure the facility have a carbon monoxide detector in the facility at all times. Proof of a purchase of a carbon monoxide detector shall be submitted to department by 05/27/24.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met as evidenced by: Based on observation, Administrator was able to provide for review the staff First Aid/CPR certification for two staff out of the four staff. Administrator did not have additional personnel records for the facility staff. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee shall ensure all required personnel documents for all staff are maintained in the facility by 5/31/23.

Deadline recorded: May 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87462(h)(2)

Regulation authority

CCR

What the official deficiency says

87462 (h)(2) 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 was not met as evidenced by: Deficient Practice Statement Licensee did not ensure all medications were centrally stored and locked when LPA arrived for inspection and observed R1’s medications in a medication cup on kitchen counter. At approximately 11:08 AM, LPA and caregiver observed two Vitamin bottles and PRN medication Nystatin Topical Powder on R2's personal table in front of the resident in the resident bedroom. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/12/2023 Plan of Correction Caregiver immediately removed the medications from R1's personal table and locked in medication drawer. POC cleared during visit.

Official classification

Type A

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, Fire Extinguisher has a service date of 07/16/2019, which poses an immediate health and safety risk to the residents.

Official plan of correction

POC Due Date: 05/13/2023 Plan of Correction Licensee shall replace or serviced fire extinguisher with a current date. Proof of correction will be submitted to the CCL office by the 05/13/23.

Official classification

Type B

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental Medical and Dental Care Services. Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, LPA reviewed all residents’ MARS and observed that they have not been updated since 05/10/23.

Official plan of correction

POC Due Date: 05/25/2023 Plan of Correction Administrator will submit documentation of staff training with staff rooster of attendance for completing MARS without errors to CCL by the POC due date of 5/25/23.