SUMMER SPRINGS BOARD & CARE

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: records reviewed and interviews completed. The licensee did not comply with the section cited above in that R1 was provided medication 2x in the am instead of 2x daily as prescribed and medication audit for R2 disclosed 4 medication errors. This poses an immediate health safety and or personal rights risk to residents in care.

Official plan of correction

Administrator stated they will provide training to all staff on medication administration and documentation. In-service sign in sheet and training material will be provided to CCL by POC date.

Deadline recorded: Mar 23, 2026. 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 requirement was not met as evidence by: record review of special incident reports submitted to the Department. Incident reports were not reported for medication errors with R1 and R2. This poses a potential health safety and or person rights risk to residents in care.

Official plan of correction

Administrator stated they will be providing In-service training to all staff on reporting requirements. In-service sign in sheets and training material will be provided to CCL by POC date as proof of correction.

Deadline recorded: Mar 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(a)(1)

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. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above in that roach baits were observed under kitchen counter stored with food. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2026 Plan of Correction Administrator immediately removed baits. Administrator stated they will be placing in a locked area not with the food.

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(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 LPA observation, the licensee did not comply with the section cited above in that food in the garage freezer was not stored properly and was undated. Food in the kitchen refrigerator/freezer was not stored properly and undated. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2026 Plan of Correction Food was immediately removed and thrown away by Administrator. Administrator stated all food will be dated coming in and stored properly.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above in that medications are being pre-poured and not being stored in the original received container.Medications are being transferred between the containers for the day and stored in the kitchen cabinet. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2026 Plan of Correction Administrator stated in service training on medication administration will be completed with all staff. An in-serivce sign in sheet and training material will be provided to CCL by POC date.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above in that Facility is not properly safeguarding resident cash. Facility has a " facility account " where all resident funds go into. Facility is not completing functional capabilities for residents in care. Pre-admission appraisals are not being completed. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2026 Plan of Correction Administrator stated they will provide a " dummy file " with the required documentation. Administrator stated they will provide a copy to CCL for review as proof of correction by POC date.

Official classification

Type B

Official code

87506

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (b)Each resident’s record shall contain at least the following information:... This requirement was not met as evidence by: records reviewed and interviews conducted. The licensee did not comply with the section cited above in that R1's file was reviewed and missing a Identification and Emergency Information (LIC 601), Pre-Placement Appraisal (LIC 603), updated Needs and Services Plan (LIC 625) , Release of Client/Resident Medical Information (LIC 605A), valid Admission Agreement. This poses a potential health safety and or personal rights risk to residents in care.

Official plan of correction

Administrator stated they have been updating records as needed. Administrator stated that since accepting R1 TSP has been provided 2x. Administrator stated they will update files and provide a sample file to CCL as proof of correction.

Deadline recorded: Mar 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

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 observations, records reviewed, and interviews conducted, staff administered R2’s Oxybutynin 5 mg on 04/05/25 and did not record in the resident’s MARs, which poses/ posed a potential health and safety risk for the person in care.

Official plan of correction

POC Due Date: 04/16/2025 Plan of Correction S1 will be retrained in in-service training on proper administering medication and documentation. Licensee will submit documentation of training topics and staff attendance to CCL by POC due date 04/16/25.

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 food was observed, which poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2025 Plan of Correction Licensee immediately disposed 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 records review and observation, staff did not administer R1’s Aspirin 81 mg and Simvastatin 20mg medication and did not administer R2’s medication Aspirin 81mg and Melatonin 10 mg as directed by physician, which poses an immediate health and safety risk for the person in care.

Official plan of correction

POC Due Date: 04/16/2025 Plan of Correction Licensee agree to write statement of steps facility will take to ensure regulations is met. Statement will be submitted to Fresno CCL by POC due date 04/16/25.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above in having a staff room/office in the garage that is not fire cleared, which poses an immediate health, safety or personal rights risk to persons in care. LPA took photos. Cvil Penalty issued.

Official plan of correction

POC Due Date: 04/18/2024 Plan of Correction Licensee agrees to remove the fully made bed for staff to sleep in or agrees to submit documents to have the room fire cleared by POC due date 04/18/24.

Official classification

Type A

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 by licensee having a syringe box that is in R1's shared room with R2 accessible to R2, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2024 Plan of Correction Licensee agrees to lock up sharps and make them inaccessible to residents. Licensee agrees to submit a written plan on how this regulation will be met by POC due date 04/18/24. Civil Penalty issued.

Official classification

Type A

Official code

87405(d)

Regulation authority

CCR

What the official deficiency says

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. 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 due to the amount of citations Administrator is not meeting the requirements of this regulation, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2024 Plan of Correction Licesnee agrees to submit a plan in writing on how the Administrator will meet the qualifications in this regulation from 1 to 7 by POC due date.

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 by not having the medication cart locked and not having the medication refridgerator locked containing morphine and insulin which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2024 Plan of Correction Licensee agrees to conduct medication training for all staff. Licensee agrees to submit who will conduct the training and the agenda for the training regarding locked medications by POC due date 04/18/24

Official classification

Type B

Official code

87411(d)(1)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning. 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 by not having a plan for daily meals for residents with modified diets, facility staff could not answer what residents were eating for dinner which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee agrees to conduct staff training on meal preparation to meet the needs of the residents by POC 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 by having bags of expired carrots expiring 10/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee agrees to dispose of expired food by POC due date 04/26/24. LPA will clear POC during visit.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. 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 by Licensee not having a diabetic diet for R1 and a low sodium diet for R3 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee agrees to submit a sample menu for a low sodium diet and a diabetic diet by POC due date 04/26/24.

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 interview record review, the licensee did not comply with the section cited above in Licensee did not have a bottle of oxycodone logged on centrally stored log which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee agrees to submit in writing on how this regulation will be met in the future and agrees to submit a copy of the medication showing logged on the centrally stored log by POC due date 4/26/24 Civil Penalty issued.

Official classification

Type B

Official code

1569.725(a)(4)

Regulation authority

HSC

What the official deficiency says

(a) A residential care facility for the elderly may permit incidental medical services to be provided through a home health agency, licensed pursuant to Chapter 8 (commencing with Section 1725), when all of the following conditions are met: (4) There is ongoing communication between the home health agency and the residential care facility for the elderly about the services provided to the resident by the home health agency and the frequency and duration of care to be provided. 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 Licensee did not have a home health care plan for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee agrees to submit a plan of care to meet the regulations by POC due date 04/26/24.

Official classification

Type B

Official code

87609(b)(4)

Regulation authority

CCR

What the official deficiency says

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). 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 Licensee did not have in writing the responsibilities of Home Health and the responsibilities of facility staff for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee agrees to have a plan in writing from the home health agency listing the responsibilities of home health and of the facility staff in caring for R2's medical condition by POC 04/26/24.

Official classification

Type B

Official code

87633(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident's hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident's or prospective resident's Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). 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 R4 not having a Hospice care plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee agrees to submit a copy of R4's hospice care plan by POC due date 04/26/24.

Official classification

Type B

Official code

87633(b)(6)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. 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 Licensee did not have training for R1's diabetic diet or for R4's medical conditions, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee agrees to obtain training through Hospice on how to meet the medical needs of R1 and R4. Civil Penalty issued.

Official classification

Type B

Official code

87633(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (5) A statement signed by the resident's roommate, if any, or any resident who will share a room with a person who is terminally ill to be accepted or retained as a resident, indicating his or her acknowledgment that the resident intends to receive hospice care in the facility for the remainder of the resident's life, and the roommate's voluntary agreement to grant access to the shared living space to hospice caregivers, and the resident's support network of family members, friends, clergy, and others. 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 by licensee not having an agreement signed by R2 for a shared room with R1 who is on Hospice which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee agrees to have the agreement signed by POC due date 04/26/24.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by adding a staff room/office which was previously the garage, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Licensee agrees to submit facility sketch adding the staff room/office, LIC200 and LIC9054 by 04/28/23. Licensee agree to submit fire clearance for additional room by 5/31/23. Civil Penalties were issued.

Official classification

Type A

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 interview, the licensee did not comply with the section cited above by disposing used needles/syringes in an uncovered trash can in R1's room, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Licensee agrees to purchase a sharps container to dispose of all sharps including needles and syringes. POC cleared during visit

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above by not obtaining a building permit to construct a staff bedroom/office in the garage, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Licensee agrees to submit a written understanding of the regulation by POC due date 05/31/23.

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 interview and record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Licensee agrees to submit CPR/First Training for all staff by POC due date 05/31/23.

Official classification

Type B

Official code

1569.696(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Licensee agrees to provide staff training for all staff to meet this regulation and submit training agenda that includes training, trainer and hours trained and sign in sheet by 5/31/23

Official classification

Type B

Official code

1569.696(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Licensee agrees to provide staff training to all staff to meet this regulation and submit training agenda that includes training, trainer and hours trained and sign in sheet by 5/31/23.

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 interview and record review, the licensee did not comply with the section cited above in 1 out of 1 record which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Licensee agrees to submit a written understanding of this regulation and how it will be met by POC due date 05/31/23.

Official classification

Type B

Official code

87616(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Licensee agrees to submit to licensing a restricted health care plan R3 by POC due date 05/31/23.

Official classification

Type B

Official code

87633(b)(4)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (4) A description of the licensee's area of responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physician, and the resident's responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Licensee agrees to submit Hospice Care Plan that meets this reglulation for R2 and submit to licensing by POC due date 05/31/23.

Official classification

Type B

Official code

87633(b)(6)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Licensee agrees to submit staff training for staff that are providing care for 3 hospice residents that meet the above regulation. Licensee agrees to submit training for staff by POC due date 5/31/23.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements - A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... Incident of resident being sent to hospital was not reported to the Department.

Official plan of correction

Admin agrees to complete & submit report for incident of resident being hospitalized & follow-up.

Deadline recorded: May 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility. Facility did not accept R1 back from hospital & did not issue required 30 Day Notice.

Official plan of correction

Admin agrees to draft Eviction Notice & submit to the Department for review, then to update & issue to R1 & /or Responsible Party. Copy of notice when issued to be sent to the Department.

Deadline recorded: May 15, 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

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 observed a bleach bottle, laundry soap and other cleaning chemical bottles stored in an unlocked laundry cabinet in the laundry room 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: 04/26/2022 Plan of Correction Administrator immediately removed the items to a locked cabinet. POC cleared during visit.