A COMFORT CARE HOME

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 Kitchen knives observed to be unlocked in kitchen drawer, medications observed to be dispensed and unlocked in drawer. Medication for R1 observed to be unlocked and in area accessible to residents. Shed in backyard unlocked and contained chemicals for pool and hazardous equipment. Chemicals observed on North side of facility were unsecured which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/06/2025 Plan of Correction All items were locked and secured at time of inspection. DEFICIENCY CLEARED AT TIME OF INSPECTION

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any reisdent. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as all exit doors in facility had auditory alarms in place but not in the " on " position which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2025 Plan of Correction All auditory alarms were placed in the " on " position during inspection, the sliding glass door in the living room needs battery to be replaced. Receipt for purchase of battery to be submitted to Fresno Regional office by plan of correction 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 nterview and record review, the licensee did not comply with the section cited above in 1 out of 2 persons did not have current CPR certification which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2025 Plan of Correction Licensee to complete CPR no later than plan of correction due date and submit certificate to Fresno Regional Office

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 in 3 out of 3 persons did not have current trainng on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2025 Plan of Correction Licensee to submit documentation for staff training and submit proof of completion to Fresno Regional Office no later than plan of correction due date.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews, the licensee did not comply with the section cited above in interview of residents and licensee facility does not provide activities for residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2025 Plan of Correction Licensee to submit activities calendar for residents to Fresno Regional office by plan of correction due date.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as LPA observed expired canned food in pantry, and leftover food and fresh fruit in refridgerator stored without having dates which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2025 Plan of Correction Licensee to ensure that all food items are properly stored and dated in the refrigeration, plan of correction to be submitted to Fresno Regional Office by due date.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the 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 4 out of 4 residents did not have centrally stored medication records which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2025 Plan of Correction Licensee to complete centrally stored medication logs for all residents and submit to Fresno Regional office by plan of correction due date.

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 as has to record of fire drill since 10/01/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2025 Plan of Correction Licensee to conduct fire drill and submit plan of correction to Fresno Regional Office by due date

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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: LPA observed medication which was pre-dispensed in an unlocked kitchen drawer. LPA observed medication requiring refrigeration to be in refrigerator and accessible to residents. Medication cabinet in hallway was unlocked. Deficient Practice Statement Based on bservation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction Licensee will keep pre-dispensed medication in locked medication cabinet in hallway. All medication requiring refrigeration will be contained in locked box in refrigerator. Medication cabinet in hallway to remain locked at all times.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: LPA observed a knives and scissors in an unlocked kitchen drawer. LPA also observed a knife in the dish rack in kitchen sink. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction All knives and sharps will remain in locked drawer and inaccessible to residents. Knives were locked and secured at time of visit. DEFICIENCY CLEARED DURING INSPECTION

Official classification

Type B

Official code

87555(26)

Regulation authority

CCR

What the official deficiency says

Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: LPA did not observe a 2-day supply of perishable food available during inspection. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction Licensee will submit grocery receipt for 2-day supply of perishable food to Fresno Regional Office no later than POC due date

Official classification

Type B

Official code

87755(9)

Regulation authority

CCR

What the official deficiency says

Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: LPA observed left over food stored in refrigerator without dates. LPA also observed canned food in the pantry beyond the expiration date. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee to ensure that all food in refrigerator is properly stored and dated. All pantry food shall be checked and expired food shall be removed from facility.

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia: The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: LPA observed auditory alarms on all exit doors, however, were not placed in the " on " position Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 4] out of 4 exit doors the auditory alarm was not in " on " position which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction Licensee to ensure that all auditory alarms remain in the " on " position. All auditory alarms were placed in the " on " position during inspection. DEFICIENCY CLEARED AT TIME OF INSPECTION.

Official classification

Type B

Official code

87468(C)

Regulation authority

CCR

What the official deficiency says

Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. This requirement is not met as evidenced by: LPA did not observe any postings upon entry to facility Deficient Practice Statement Based on observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee to ensure all required postings are posted in facility near entry point.

Official classification

Type A

Official code

1569.2(c)

Regulation authority

HSC

What the official deficiency says

" Care and supervision " means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. ***This was not met as evidenced by LPA interviews that staff are not present at night.

Official plan of correction

Licensee will have staff present at night beginining 9/28/23 until a night staff is hired.

Deadline recorded: Sep 28, 2023. A deadline is not proof that correction was completed.