COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INC

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 4 out of 6 residents were documented to be non-ambulatory/bedridden on their Physician Reports which is not current with their fire clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/09/2025 Plan of Correction The Licensee will email LPA Segovia the Physician Report for R5 for non-ambulatory to ambulatory due Physician Report. Additionally, licensee will email LPA Segovia the process with the fire department regarding their fire clearance violation.

Official classification

Type A

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 and record review, the licensee did not comply with the section cited above in 2 of 2 residents medications checked were not updated correctly on their medication log which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/09/2025 Plan of Correction The Licensee will review the entire regulation and email LPA Segovia a statement of understanding.

Official classification

Type B

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 2 out of 6 residents were missing their Pre-Appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2025 Plan of Correction The Licensee will email LPA Segovia the Pre-Appraisal for both residents.

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 observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 6 residents were missing their Re-Appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2025 Plan of Correction The Licensee will email LPA Segovia the Re-Appraisal for all three residents.

Official classification

Type B

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's record review, the licensee did not comply with the section cited above as S1 has no health screening record on file which poses a potential health and safety risk to the residents in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction The administrator agreed to obtain a health screening for S1 and submit a copy to CCL on or before the POC date.

Official classification

Type B

Official code

87705(c)(5)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's record review the licensee did not comply with the section cited above in 1 out of 4 resident records reviewed R1 has dementia diagnosis with no updated medical assessment, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction The administrator agreed to obtain an updated LIC 602 for R1 and submit a copy to CCL on or before the POC date.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87309 Storage Space (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 was not met as evidenced by: Based on observations made during LPA's annual visit, the cleaning supplies underneath the kitchen sink and washing detergent in the laundry room were not locked which poses a potential health, safety and personal rights risk to residents in care.

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

Official classification

Type B

Official code

87470(c)(f)

Regulation authority

CCR

What the official deficiency says

87470 Infection Control Requirements (c) An Infection Control Plan shall be developed . (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 was not met as evidenced by: Based upon LPA's interview of the reporting party, the facility staff did not record the reporting party's temperature until prompted by the reporting party, which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Upon entering the facility, LPA's temperature was taken and COVID questions recorded at the sign in station.

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

Official classification

Type B

Official code

87470(5)(b)(2)

Regulation authority

CCR

What the official deficiency says

All staff and volunteers providing direct care to a resident....shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents...This requirement was not met as evidenced by: Upon entering the facility, LPA observed staff member was not wearing a mask which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will conduct training for staff regarding infection control guidelines. Administrator will provide to LPA signature of staff members who participated in the training.

Deadline recorded: Jun 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

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 was not met as evidenced by; LPA observed the cleaning supplies were stored underneath the sink but the cabinet was not locked which poses an immediate health and safety risk to residents in care.

Official plan of correction

At 12:25 pm, LPA observed caregiver locked the cabinet. LPA stated staff need to ensure the cabinet is locked at all times.

Deadline recorded: May 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87355 Criminal Record Clearance (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement is not met as evidenced by: Based on LPA Spaeth observing a individual in the facility mopping the floor, LPA was told the person was not a staff member and has been visiting for the past three weeks.

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