DURANDO HOME, INC.

Official classification

Type A

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 interview and record review, the licensee did not comply with the section cited above in 1 out of 1 Staff member (S1) did not have Cardiopulmonary Resuscitation (CPR)/ First Aid certificate. S1 was the only caregiver on duty when LPA arrived which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2025 Plan of Correction The Administrator will email LPA Segovia the completion of S1's CPR/First Aid certificate.

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 3 residents were missing their Re-appraisals which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2025 Plan of Correction The Administrator will email LPA Segovia the completed and updated Re-appraisals for all 3 residents

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 (a) Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record reviews the Administrator failed to accompany or have staff accompany R1 to the hospital leaving R1 by themselves. This poses a potential health and safety risk to residents in care.

Official plan of correction

POC Administrator agrees to have designated staff to accompany residents to all medical appointments or any appointments that require the resident to leave the facility. A new LIC500 will be submitted to LPA by POC due date via email to reflect additional necessary staff.

Deadline recorded: May 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

87463 (c) Reappraisals (c) The licensee shall arrange a meeting with the resident…when there is a significant change in the residents’ condition...whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidence by: Based on interviews and record reviews the Administrator failed to meet with R1 at the hospital for a reappraisal. This poses a potential health and safety risk to residents in care.

Official plan of correction

POC Administrator agrees to submit a new reappraisal for all residents in care via email, to LPA, by POC due date.

Deadline recorded: May 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

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...care shall be developed by each facility. (1)The licensee shall arrange...medical and...appropriate to the conditions and needs of residents. This requirement is not met as evidence by: Based on interviews, record reviews and observations the Administrator failed to follow hospital release instructions for R1 based on hospital discharge paperwork. This poses a potential health and safety risk to residents in care.

Official plan of correction

POC Administrator agrees to provide in-service training for all staff regarding preparing a plan of care for residents when there is a change in care. Training log will be provided to LPA via email by POC due date.

Deadline recorded: May 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

87555General Food Service Requirements(b)The following food service requirements shall apply: (26)Supplies ... and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on LPA’s view of the food supply, the licensee did not comply with the section cited above in not providing a two day supply of perishable foods this poses a Health, Safety, and Personal risk to residents in care.

Official plan of correction

Administrator purchased perishable food that was delivered to the facility on day of visit. Administrator will provide a weekly menu to LPA via email for the next six weeks.

Deadline recorded: Jan 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency …(1) A written report shall be submitted to the licensing...within seven days of the occurrence ...This report shall include… disposition of the case. This requirement is not met as evidenced by: Based on interviews with staff, witnesses and file reviews, the Administrator failed to report incidents that happened to resident in Durando Home Inc. to CCL within 7 days which poses a potential health and safety risk to residents in care.

Official plan of correction

All staff will take state approved vendorised training on Reporting Requirements. Administrator will submit training material and staff sign in sheet to LPA via email by 02/02/2024.

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

Official classification

Type B

Official code

87219(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation and staff interview, the licensee did not comply with the section cited above in one out of four residents not having any activities calendar on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2023 Plan of Correction Administrator will provide a copy of activity calendar by POC due date via email or text.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement is not met as evidenced by: Deficient Practice Statement Based on record reviewand staff interview, the licensee did not comply with the section cited above in three out of three staff records that were missing annual trainings and two of three staff records were missing CPR and First Aid certifications which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/20/2023 Plan of Correction Administrator will have all staff complete all required training mentioned in HSC 1569.625 and 1569.69. Administrator will send name of training and hours completed to LPA via email by POC due date.

Official classification

Type B

Official code

1796.37(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) THe department may issue a home care organization license to a home care organization applicant that satisfies the requirements...(2) Submits proof of general and prefessional liability insurance in the amount of at least one million dollars ($1,000,000) per occurance and three million dollars ($3,000,000) in the aggregate. 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 due to not having a liability insurance when they are responsible for safeguarding cash resources which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2023 Plan of Correction Admiistrator will provide LPA a copy of the certificate of liability insurance via email by POC due date.