COTTAGES OF LAKE BALBOA 3, THE

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above in two out of five personnel files were not available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2025 Plan of Correction Licensee/Administrator will email LPA Plan of Correction to ensure all Staff files are available for review at the time of inspection.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 as cleaning solutions were observed unlcked in a cabinet under the sink, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2024 Plan of Correction Cleaning and desinfectatnts were loceked at the time of the visit.

Official classification

Type A

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 observation the licensee did not comply with the section cited above in thwo out of three medications were not dispensed correctly, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2024 Plan of Correction Administrator will contract a vendor to consucte training on how to fill out the Centrally stored medication form and dispense the medications.

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 the licensee did not comply with the section cited above in one room it was detected a strong smell of urine, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2024 Plan of Correction Corrected on the day of the visit.

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 observation, the licensee did not comply with the section cited above in four staff out of four staff did not have CPR training, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2024 Plan of Correction Administrator will provide proof of training by sending a copies of the CPR certificate.

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 four out of staff didnot have on file the 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: 09/09/2024 Plan of Correction Administrator will send proof of training to LPA by the POC due date

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(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 as one out of six residents bed had full bed rails without a doctor's order, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2024 Plan of Correction Administrator will email to LPA proof of the doctor's order for a full bed rail.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465(h)(5) Incidental Medical and Dental Care - Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Based on observations and interview, LPA the licensee did not comply with the section cited above as (6) residents had medications pre-poured and out of their original containers for more than 24 hours which poses a potential health risk to persons in care.

Official plan of correction

Licensee agreed to review section cited and provide a statement of understanding to CCL via email by EOD 11/03/2023.

Deadline recorded: Nov 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... of adequate services. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the regulation cited above in that staffing was not sufficient in numbers to provide needed services to R1 who required 2 person assist which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Licensee has agreed review section cited and to write a Statement of Understanding and send to CCL via email by 10/20/23.

Deadline recorded: Oct 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(a)

Regulation authority

CCR

What the official deficiency says

Admission Agreement: (a)The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement was not met as evidenced by: The facility failed to complete an Admission Agreement for Resident #1.

Official plan of correction

The Licensee will review all residents file to ensure that there is a completed Admission Agreement in their file. Licensee will submit a written statement indicating that all resident files have been reviewed and all files contain a completed Admission Agreement by 2/24/23

Deadline recorded: Feb 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance:(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department or (f) Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department. This requirement is not met as evidenced by:

Official plan of correction

Licensee will not allow S1 to work at facility until criminal record clearance obtained. Submit plan of correction to CCL by 3/28/2022. Based on records review, the licensee did not comply with the section cited above. S1 was not listed on the LIS, timecards and interviews indicated S1 worked at the facility without a criminal record clearance, which posed an immediate health and safety risk to residents in care.

Deadline recorded: Mar 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(A)

Regulation authority

CCR

What the official deficiency says

Postural Supports:(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: Based on observation by Investigator Santana, the licensee did not comply with the section cited above. Half bed rails are engaged on R1’s bed at night, which posed a potiential health and safety risk to residents in care.

Official plan of correction

Licensee may submit copy of doctor's order for the half bed rails and indicate they will be used solely for the purpose of assistance with mobility or provide proof of coorection to regulation cited by other means after discussing with case LPA before due date. Submit correction by 4/1/2022 to CCL.

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

Reappraisals:(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition... This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. R1 Needs and Services Plan dated 06/01/2021 did not contain accurate, current information, which posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee to submit copy of R1’s current, accurate Needs and Services Plan, signed and dated by both licensee and R1 or R1’s representative. Submit to CCL by 4/1/2022.

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(2)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not ensure R1's sheets were regularly changed, which poses a potential health risk to residents in care.

Official plan of correction

Licensee conducted a staff training on 11/17 and 11/18/2021 including basic services training. POC met at this time.

Deadline recorded: Dec 3, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...dressing...bathing and assistance with taking prescribed medications, as specified in Section 87608... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not ensure R1's skin remained clean and dry, and incontinece needs were met, which poses a potential health risk to residents in care.

Official plan of correction

Licensee conducted a staff training on 11/17 and 11/18/2021 including basic services training. POC met at this time.

Deadline recorded: Dec 3, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing...in Section 87608, Postural Supports. This requirement is not met as evidenced by: Based on observation and interviews, R1's hair had not been washed or brushed regularly, which poses an immediate health and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to immediately ensure staff are regularly offering to wash R1's hair and ensure all residents' personal care needs are met. Additional training to be provided to staff on working with R1. Administrator will provide CCL with a detailed plan on how the facility will handle care refusal including who will be notified and when care needs are refused by 11/10/2021.

Deadline recorded: Nov 3, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on observation and interviews, facility staff have raised their voice with R1 and do not respond timely to R1's requests for assistance, which poses an immediate personal rights risk to residents in care.

Official plan of correction

Licensee agreed to train all staff on section 87468.1. Training to be held and a copy of the roster including information on trainer, attendees, topics covered, date and duration of training to be sent to CCL by POC due date.

Deadline recorded: Nov 16, 2021. A deadline is not proof that correction was completed.