HOUSE OF GRACE 3

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 as two (2) out of three (3) staff files did not contain proof of the required additional 20 hours of annual training, which poses/posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/29/2025 Plan of Correction The licensee agrees to ensure all staff complete the required 20 hours of annual training. The licensee will submit proof of completed annual training for the two (2) staff identified, along with a training schedule and tracking system to ensure ongoing compliance. Proof of correction will be submitted to the Department by the POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 six (6) out of six (6) resident files did not contain updated re-appraisals, which poses/posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/29/2025 Plan of Correction The licensee agrees to complete updated re-appraisals for all six (6) residents. The licensee will submit copies of the completed re-appraisals to the Department by the POC due date. In addition, the licensee will implement a tracking system to ensure future re-appraisals are completed and maintained in accordance with regulatory requirements.

Official classification

Type B

Official code

87211(a)(1)(2)

Regulation authority

CCR

What the official deficiency says

(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* Licensee will send report and retrain by 8/13/24. case.(A)Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.(C) The use of an Automated External Defibrillator. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

Official plan of correction

(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the-

Deadline recorded: Aug 13, 2024. 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 temperatures in grooming faucets were above 120 degree F, the licensee did not comply with the section cited above in 6 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: 12/08/2023 Plan of Correction Licensee lowered water heater during visit. Licensee will develop water log and record water temperatures for residents grooming faucets for the next 7 calender days. Licensee will send log to LPA Ramirez via email by 12/14/23. Licensee will train staff on regulation above and send proof training attendance to LPA Ramirez by 12/14/23.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, water temperature taken in kitchen sink was measured to be 141 degrees F and was not prominetly identified by warning signs, the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction Licensee will place warning signs above taps delivering water at 125 degree F or above. Must send picture proof of sign placed above kitchen sink.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

CCR

What the official deficiency says

1569.625 Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, staff #1 training record did not document required 6 hours of dementia care with 4 weeks of employment, the licensee did not comply with the section cited above in 1 out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Licensee will certify via email plan to comply with above regulation for future staff.

Official classification

Type A

Official code

87705(g)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. (1) Evidence means documentation from the resident’s physician that the resident is at risk if allowed direct access to personal grooming and hygiene items. 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 2 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: 12/08/2023 Plan of Correction Licensee removed razor during visit. Licensee will re-train staff according to above regulation and send proof of training by 12/14/23 via email.