FIL-AM HOME FOR SENIORS III

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department This requirement was not met as evidenced by: S1 and S2 did not obtain a California clearance or exemption as required. This poses an immediate risk to the health, safety, or personal rights of persons in care.

Official plan of correction

Administrator Miclat will draft a plan on how future staff/and or volunteers will obtain criminal clearance or exemption prior to working or volunteering at the facility. Plan must be received by 08/14/2026, via email.

Deadline recorded: Aug 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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. One (1) out of four (4) staff files did not contain TB test results or physical examinations, which poses/posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2026 Plan of Correction The licensee agrees to ensure all S2 obtains a TB tests and physical examination. Proof of completed TB tests and physical exams for S2 will be submitted by the POC 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 record review, the licensee did not comply with the section cited above in (1) out of (4) staff did not have a current CPR and First Aid certification on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2026 Plan of Correction Licensee will submitted updated CPR and First Aid certificate for S4 by POC due date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 two (2) out of four (4) residents did not have a TB examination on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2026 Plan of Correction Licensee will submit proof of TB examination for R1 and R2 by POC due date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 one (1) out of four (4) residents did not have a physciand order for bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2026 Plan of Correction Licensee to submit proof of physicians order for bed rails for R1 by POC due date.

Official classification

Type A

Official code

87629

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. 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 one (1) out of five (5) residents requires assistance with the administration of injectable medication Enoxaparin (blood thinner) every 12 hours which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Licensee to submit a plan on how the facility will meet this regulation by POC due date.

Official classification

Type A

Official code

87628

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. 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 one (1) out of five (5) residents require assistance with the administration of injectable medication Lantus for Diabetes which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Licensee to submit a plan on how the facility will meet this regulation by POC due date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(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 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 one (1) out of five (5) residents did not have a prescribed medication Albuterol (as needed) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Submit a plan on how licensee will submit proof of medication being discontinued or submit proof of current medication order by physician and refill date.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608(a)(3) 87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (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 evidence by: LPA observed R1 with double half rails and Administrator stated that the facility did not have a doctor’s order for the half bed rails that were used for R1 and R6 bed which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator will obtain doctor's orders for R1 and will read section 87608 and send a written letter to LPA indicting that Administrator understood the section and how it facility will prevent this from happening again by POC date.

Deadline recorded: May 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)(c)

Regulation authority

CCR

What the official deficiency says

87464(f)(1)(c) Basic Services: Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). H & S Code 1569.2(c) “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. This requirement is not being met as evidenced by: Based on interviews and record review, resident suffered 2 facial fractures while in care at the facility and facility failed to provide medical attention to resident. Lack of care and supervision by facility resulted in staff not knowing resident had facial fractures. The fractures were discovered when resident made visit to emergency room for unrelated health issues.

Official plan of correction

Licensee to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to train staff on providing care and supervision and send roster with signatures of participants of training to LPA. Licensee to submit a faxed copy of POC by due date of 05/01/2024 Immediate $500 dollar penalty assessed.

Deadline recorded: May 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465(a)(1) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and record review, facility did not contact PCP or arrange to have wound care specialist provide wound care to resident who was admitted to facility with two stage 1 pressure injuries on both heals and developed stage 3 pressure injury on coccyx while in care.

Official plan of correction

The administrator shall develop a written plan to ensure that residents receive medical attention while in care. The plan shall also include the steps the facility will take when a resident's health condition declines or refuses. This POC is due to LPA by 05/01/2024

Deadline recorded: May 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, cleaning supplies were observed to be accessible in bathroom#1 sink cabinet, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/10/2024 Plan of Correction Staff removed cleaning solutions after discovery and placed in secure area. Licensee will re-train staff on above regulation and send proof of re-training by 02/23/2024.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, Licensee could not provide documentation of liability insurance when requested, the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Licensee will obtain liability insurance per Title 22 regulations and maintain insurance. Proof of insurance must be submitted via email by 2/16/24.

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, facility is not conducting drills at least quarterly,the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Licensee will conduct drills according to above regulation and re-train staff on regulation. Proof of re-training due by 02/16/2024 via email.

Official classification

Type B

Official code

87470(c)(1)(F)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not being met as evidenced by: LPA observed that staff #1 was not wearing his N95 mask properly on today's visit. And, Staff #1 was not wearing a mask on 12/29/22 visit and did not screen visitor, until prompted by administrator.

Official plan of correction

Administrator will ensure that facility is following California Dept of Public health and CCLD requirements. Administrator will provide a written statement stating that staff have been trained, and will comply with CDSS requirements and regulations, and will maintain a safe and healthful environment for residents and staff.

Deadline recorded: Feb 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not being met as evidenced by: LPA observed that facility front door, is locked and can only be unlocked with the key that only staff has access to.

Official plan of correction

Administrator will ensure that the front door lock is changed, so that it can be unlocked without the use of a key. Administrator will send proof of correction to LPA by POC due date.

Deadline recorded: Feb 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not being met as evidenced by: LPA observed that the kitchen door(s) have locks on them. One door, is a sliding pocket door, that has a hook with a latch. The other door has a lock on the door knob.

Official plan of correction

Administrator will ensure that the kitchen doors are no longer locked, and that locks are removed from door(s). Administrator will send proof of correction to LPA by POC due date.

Deadline recorded: Feb 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.50(a)(3)

Regulation authority

HSC

What the official deficiency says

(a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not being met as evidenced by: LPA observed that staff #1 was not wearing his N95 mask properly on today's visit. And, Staff #1 was not wearing a mask on 12/29/22 visit and did not screen visitor, until prompted by administrator.

Official plan of correction

Administrator will ensure that facility is following California Dept of Public health and CCLD requirements. Administrator will provide a written statement stating that staff have been trained, and will comply with CDSS requirements and regulations, and will maintain a safe and healthful environment for residents and staff.

Deadline recorded: Jan 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not being met as evidenced by: LPA observed that facility front door, is locked and can only be unlocked with the key that only staff has access to.

Official plan of correction

Administrator will ensure that the front door lock is changed, so that it can be unlocked without the use of a key. Administrator will send proof of correction to LPA by POC due date.

Deadline recorded: Jan 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1

Regulation authority

HSC

What the official deficiency says

a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not being met as evidenced by: LPA observed that the kitchen door(s) have locks on them. One door, is a sliding pocket door, that has a hook with a latch. The other door has a lock on the door knob.

Official plan of correction

Administrator will ensure that the kitchen doors are no longer locked, and that locks are removed from door(s). Administrator will send proof of correction to LPA by POC due date.

Deadline recorded: Jan 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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,water temperature in resident bathroom#2 was measured at 121.6 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/30/2022 Plan of Correction Administrator/ Licensee will maintain a water temperature log and staff will document water temperature every 24hrs for the next 3 calendar days. Administrator/ Licensee will send proof of log and first water temperature reading by POC due date and final log with temperature reading by 01/02/2023.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(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, medication for Resident #2 (R2) contained Acetaminophen that was not prescribed by a physican but was located in R2's medication storage box and client did not take medication as prescribed on 12/20/22, 12/21/22, 12/25/22 and 12/26/22, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2023 Plan of Correction Administrator/ Licensee will ensure resident takes medication as prescribed by a physican. Administrator/ Licensee will retrain staff on medication procedure and provide proof of training completeion. Administrator/ Licensee removed unprescribed medication while LPA was present.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 is not met as evidenced by: Deficient Practice Statement Based on observation, shared/resident bathroom#1 light was not working at the time of the visit. Sink and bath tub in shared/resident bathroom#1 was dirty with soap residue and hair, light in resident bathroom#2 was not working during the visit, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2023 Plan of Correction Administrator/Licensee will replace light bulbs in both bathrooms, clean sink and tub in shared/resident bathroom#1. Photo proof will be submitted.

Official classification

Type B

Official code

87307(a)(3)(D)

Regulation authority

CCR

What the official deficiency says

(D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation,toliet paper was not observed in shared/resident bathroom#1, paper towels and toilet paper were not present in resident bathroom#2, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/30/2022 Plan of Correction Administrator/licensee will keep bathrooms stocked with toilet paper and soap. Administrator/licensee corrected while LPA was present.

Official classification

Type B

Official code

87307(d)(5)

Regulation authority

CCR

What the official deficiency says

(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, no nightlight was observed in hallway leading to resident bathroom#2, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/30/2022 Plan of Correction Administrator/Licensee will place a nightlight in hallway and send photo proof to LPA. Administrator/Licensee corrected while LPA was present.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, Administrator/Licensee could not provide such proof and stated liability insurance was expired, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2023 Plan of Correction Administartor/Licensee will provide current proof of liability insurance.

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 record review,staff 2 (S2) was not associated with the facility, administrator/licensee was asked by this department to associate S2 on 12/07/2022 but did not comply, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2023 Plan of Correction Administrator/Licensee will associate staff 2 (S2) on Guardian and provide LPA with proof.

Official classification

Type B

Official code

87412(a)(4)

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: (4) Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, staff1 (S1) was missing social security information on personnel records and copy of drivers license or birth certificate, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2023 Plan of Correction Administraor/Licensee provided LPA with an email of S1's out of country passport.

Official classification

Type A

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

Health Related Services. Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. This requirement was not met by evidence of: LPA and administrator observed medications listed on 809 that did not belong to residents and/or had expired which poses a health and safety treat to residents in care

Official plan of correction

Administrator will dispose properly of expired medications by delivering them to a pharmacy and make a list of items that were taken to be destroyed and send proof to LPA by POC date

Deadline recorded: Dec 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

87555(b)(9) General Food Service Requirements. 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 and administrator observed items of expired food. (see list on 809) which poses a health and safety threat to residents in care

Official plan of correction

Administrator disposed of all exired food and will rotate food in storage to prevent facility food from expiring. Administrator will send a written plan to LPA by POC date on how they will address the issue.

Deadline recorded: Dec 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705(f)(1) Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to resident(s). This was not met as evidenced by: LPA and administrator observed knife in unlocked drawer in kitchen which poses a health and safety threat to residents in care.

Official plan of correction

Administrator locked the knife during the visit, ***no further action is required***

Deadline recorded: Dec 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 is not met as evidenced by: LPA and administrator observed refrigerator in garage in uncleaned condition which poses a health and safety threat to persons in care.

Official plan of correction

Administrator will clean the refrigerator in the garage and send photo as proof to LPA by POC DATE.

Deadline recorded: Dec 6, 2022. A deadline is not proof that correction was completed.