OUR SWEET HOME INC

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 record review, the licensee did not comply with the section cited above in [two] out of [ two ] Resident's medication, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/05/2023 Plan of Correction As POC, licensee will conduct staff training to address this section of the regulations. As proof training was made, licensee will submit a training log with attendance sheet to the licensing agency by 10/05/23.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. 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 [two] out of [ two ] Resident's medication, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/05/2023 Plan of Correction As POC, licensee will conduct staff training to address this section of the regulations. As proof training was made, licensee will submit a training log with attendance sheet to the licensing agency by 10/05/23.

Official classification

Type A

Official code

87470(c)(1)(f)

Regulation authority

CCR

What the official deficiency says

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 by not screening visitors, following coid protocols or wearing masks which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2022 Plan of Correction Administrator agrees to hold an inservice with staff regarding this requirement and submit a sign in sheet and training materials as POC

Official classification

Type A

Official code

87608(a)(5)(b)

Regulation authority

HSC

What the official deficiency says

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 by using a full bed rail without a prescription which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2022 Plan of Correction The administrator will provide a copy of the prescription of the bed rail and put into writing her understanding of this regulation

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

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 iby not having a sufficient amount of perishable foor which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2022 Plan of Correction Administrator agrees to provide the LPA with a receipt of the food purchased

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met evidenced by: Based on record review observations during the visit dated 9/1/21) in reference to complaint # 31-AS-20210824091525, residents' files were incomplete and/or missing required forms. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will review Title 22 regulations section 87506(b)(1-17) as a guide to ensure compliance with the regulation. Licensee/administrator will review update/complete all residents records including hospice records for the hospice residents. Once the files have been updated/completed licensee administrator will submit a written notidication to the department confirming that the resident files are all updated and completed

Deadline recorded: Apr 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

Safeguards for Resident Cash, Personal Property, and Valuables. (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources This requirement is not met as evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by not retaining receipts for items purchased with residents P & I which posed a personal rights violation to residents in care.

Official plan of correction

The Licensee will refund P & I funds to two (02) residents of Brilliant Corners as described in Audit report and furnish Regional Office and Brilliant Corners proof of repayment. The documents must be provided to CCLD by POC due date.

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Every facility shall account for any cash resources entrusted to the care or control of the licensee or facility staff. (1) Cash resources include but are not limited to monetary gifts, tax credits and/or refunds, earnings from employment or workshops, and personal and incidental need allowances from funding sources such as SSI/SSP. This requirement is not met as evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by not distributing P & I funds to residents (R1 & R2), and not keeping proper records of funds entrusted to her which posed a personal rights violation to residents in care.

Official plan of correction

Licensee agrees to: 1. Pay back residents (R1 & R2) all P & I amounts due. Licensee owes: Resident (R1) $1242.00 Resident (R2) $966.00 2. Submit proof (bank statements) that the amounts due were issued to R1 & R2.

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(e)

Regulation authority

CCR

What the official deficiency says

(e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability the licensee incurs in the use of his own or the facility's funds and valuables. This requirement was not met evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by commingling facility funds with personal and incidental funds. This posed/poses a personal rights risk to persons in care.

Official plan of correction

Licensee/administrator agrees to open a bank trust account for the residents P & I and deposit residents' P & I funds into the trust account only. Facility bank account should not have any residents' P & I monies. Provide copies of bank statements showing P & I funds have been deposited into a trust account.

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87216(a)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file, or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. The amount of the bond shall be in accordance with the schedule listed under this regulation. This requirement was not met evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by acknowledging that a surety Bond was not in place prior to this complaint investigation which poses a health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee agrees to Obtain and submit a copy of the Surety Bond for each facility by POC due date. NOTE: The Surety Bond should cover the facility, and not the corporation.

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by providing inaccurate information and documentation to Department of Health Services and Community Care Licensing

Official plan of correction

Licensee/Administrator will schedule vendorized training related to the cited section as well as 87408: Denial or Revocation of a Certificate 87777: Exclusions Personal Rights. Verification of scheduled training with the trainers credentials will need to e submitted by 4/29/2022 and completed by 5/13/2022.

Deadline recorded: Apr 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2-3)(5)

Regulation authority

CCR

What the official deficiency says

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. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (3) Ability to maintain or supervise the maintenance of financial and other records (5) Good character and a continuing reputation of personal integrity. This requirement was not evidenced by: Based record review and interview conducted during the audit investigation the Licensee failed to maintain accurate financial records; and provided DHS and CCL inaccurate documentation and information.

Official plan of correction

Licensee/Administrator will schedule vendorized training related to the cited section as well as all other sections cited on this report Verification of scheduled training with the trainers credentials will need to e submitted by 4/29/2022 and completed by 5/13/2022.

Deadline recorded: May 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87215

Regulation authority

CCR

What the official deficiency says

Money and valuables of residents entrusted to the licensee of one community care facility licensed under a particular license number shall not be commingled with those of another residential care facility for the elderly of a different license number, regardless of joint ownership. This requirement was not met evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by commingling facility funds with personal and incidental funds. Licensee misappropriated residents personal and incidental (P & ) funds. which posed a health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee agrees to provide a copy of the bank statement showing P & I funds have been deposited into a trust account. Submit by POC due date.

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.