LEISURE GARDEN SENIOR ASSISTED LIVING FACILITY

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary... at all times. Maintenance shall include...for the safety and well-being of residents... This requirement is not met as evidenced by: LPA observed a bed bug on the mattress of one of the thirteen rooms toured which poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

The licensee agreed to have fumigation services provided to the room affected including the surrounding areas of the facility. Additionally, the licensee will order protective mattress covers and dispose of the affected mattress. Proof will be emailed to LPA Segovia by POC due date.

Deadline recorded: Oct 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

87468.1 (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by; Based on observations and interviews, the licensee is using the office as entrance and exit for residents and door has locking mechanism for residents trying to EXIT the building which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

A plan of correction was not issued at this time as the facility took corrective measures in the presence of LPA.

Deadline recorded: Sep 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation: 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: Based on inspection, and observation the Licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed cockroachesin the hallway. This poses a potential health, safety risk and personal rights violation to residents in care.

Official plan of correction

The Administrator will take all measures to maintain the facility free from cockroaches. Administrator will submit updated documentation of Pest Control service agreement to LPA by POC date.

Deadline recorded: Apr 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal (c)Prior to admission... (1)The appraisal shall document, at a minimum:(A) An evaluation of the prospective resident's functional capabilities,... as specified in Sections 87459, Functional Capabilities... This requirement is not met as evidenced by: Based on interviews and resident records review the licensee failed to conduct a proper preplacement evaluation with R1 to make sure the facility was suitable for R1 which is an immediate health and safety risk to resident in care.

Official plan of correction

The Administrator has agreed to the following: 1. Since R1 is still in the facility a Re appraisal and Appraisal needs and services will be conducted. 2. Staff responsible of placement/intake will take " Pre-admissions appraisal " in-service training and Submit training schedule, training material and sign in sheet to LPA by POC due date.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on LPAs' observation and interviews, the facility keep one (1) of (2) two exit doors on the second floor locked, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

POC was cleared 11/27/2024. Administrator contacted LPA to inform them the door has been disengaged by the Door Dr. a company the facility uses.

Deadline recorded: Nov 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(3)

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: (3) Fires... which occur in... the premises shall be reported no later than the next working day to the licensing agency. This requirement is not met as evidenced by: According to record reviews the facility failed to report a facility fire to CCL the next working day which poses an potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee will submit a statement of understanding on the allegation cited by POC due date 12/02/2024.

Deadline recorded: Dec 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(6)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation as specified in Section 87465… This requirement is evidenced by: The facility staff did not provide R1 transportation to their doctor's appointment which poses an immediate health and safety risk to residents in care.

Official plan of correction

LPA Spaeth discussed with the Administrator the facility program states the facility will provide transportation services per the program design.

Deadline recorded: Sep 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement is not met as evidenced by: Based on interviews conducted, the facility did not take appropriate action to mitigate R1 from sustaining an unexplained injury although facility was aware of R1's change in condition which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

R1 is no longer in the facility. Administrator agrees to conduct in-service training with all staff regarding regulation cited and develop a plan to ensure resident changes in condition are addressed accordingly and included in the needs/services plan. Provide as proof sign in sheet of staff attendance by POC due date.

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 (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 was not met by evidence of: Based on interviews conducted with residents and staff, the facility did not take appropriate action to mitigate treatment of R1 by other residents' increasing aggressive behavior towards R1, which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

R1 is no longer in the facility. Administrator agrees to conduct in-service training with all staff regarding regulation cited. Provide sign in sheet of staff attendance as proof of correction to CCLD by POC due date.

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...This was evidenced by: LPA observed one of the two elevators was not working which poses an immediate health, safety or personal rights risk to person in care.

Official plan of correction

During LPA's visit, the elevator repair company was contacted and the elevator was repaired during LPA's visit.

Deadline recorded: Jul 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

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... and a reappraisal done at least annually... This requirement was not met by evidence of: Based on interviews conducted with staff and residents and record review conducted by LPA, the licensee failed to have R1 receive an annual medical assessment which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator will provide a copy of R1's medical assessment/physician's report and updated appraisal needs and services when completed to LPA by POC due date 06/10/2024.

Deadline recorded: Jun 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

HSC

What the official deficiency says

87303 Maintenance & Operation (a) The facility shall be clean, safe, sanitary at all times. Maintenance shall include...mainte- nance services & procedures for the safety and well-being of residents, ....This is evidenced by: Based on LPAs observations and staff interview, the licensee did not comply with the section cited above by not ensuring the facility is free of bed bugs. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to request the professional service spray the entire facility.

Deadline recorded: May 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

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: (2) To be accorded safe, healthful and ….furnishings and equipment. This requirement is not met as evidenced by: Based on LPAs interviews, the licensee did not comply with the section cited above by not ensuring the storage room door was locked. The door was unlocked and R1 left the facility unassisted by staff. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to providing a sign in sheet for all staff stating all exit doors will be checked at the beginning of each shift.

Deadline recorded: May 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation: 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: Based on LPAs observation licensee did not comply with the section cited above, by not ensuring that three (3) out of five (5) resident rooms are in good repair. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to submit proof of picture or an invoice with by POC date.

Deadline recorded: Mar 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(f)(1)

Regulation authority

HSC

What the official deficiency says

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by: Based on LPAs observation, the licensee did not comply with the section cited above by not having the evacuation chair in their stairwell, which poses/posed a potential health, safety or personal rights risk to persons in care

Official plan of correction

The licensee agreed to purchase the evacuation for each stairwell at the facility and will submit the proof of purchase to CCL on or before the POC date.

Deadline recorded: Mar 15, 2024. 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

87217(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... This requirement was not met by evidence of: Based on interviews conducted with staff and residents the licensee failed to take appropriate measures to return residents' personal property after laundry service which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

The Licensee will create a laundry service procedure that will ensure residents' clothing is returned to them and review procedure with staff. Once completed Licensee will send a copy of laundry procedure and a staff signed in sheet indicating the laundry procedure has been reviewed by them. Submit documentation to LPA by POC due date.

Deadline recorded: Mar 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical & Dental Care (g) The licensee shall immediately telephone 911 if an injury,... has resulted in an imminent threat to a resident’s health including,.. an apparent life-threatening medical crisis...This requirement was not met as evidenced by: Based upon staff interviews, staff failed to call 911 when staff observed the resident had experienced pain and discomfort which poses an immediate health & safety risk to residents in care.

Official plan of correction

The Administrator will develop and implement staff training regarding proper documentation of resident's decline in health and procedures in reporting the residents decline in health. Administrator will provide a staff sign in sheet when staff has completed the training.

Deadline recorded: Mar 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in... physical,..functioning & ...assistance is provided... When changes...are observed, the licensee shall ensure that changes are brought to attention of resident's physician... This requirement was not met as evidenced by: Staff interviews revealed the changes in R1's health were not brought to the physician's attention in a timely manner, which poses an immediate health & safety risk to residents in care.

Official plan of correction

The Administrator will develop and implement staff training regarding proper documentation of resident's decline in health and procedures in reporting the residents' decline in health. Administrator will provide a staff sign in sheet when staff has completed the training.

Deadline recorded: Mar 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, ... those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 pressure injuries. This requirement is not met as evidenced by: Facility staff failed to adequately address the resident’s pressure injuries which poses an immediate health risk to persons in care.

Official plan of correction

Administrator will provide staff training regarding proper documentation for repositioning residents in care. Administrator will provide staff sign in sheet for the training provided. During todays visit LPA issued a Civil Penalty of $500.

Deadline recorded: Feb 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a) Each licensee shall furnish to the licensing agency... the following:(1)A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the section cited above as evidence by a special incident report for R1 was not submitted to CCL which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will submit an incident report for the incident described on this report and a written statement that all incident reports will be reported in a timely manner by poc due.

Deadline recorded: Jan 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(16)

Regulation authority

CCR

What the official deficiency says

a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To written notice of any room changes at least 30 days in advance ... This requirement has not been met as evidenced by interviews the facility failed to provide written notices to residents which poses a potential safety risk to this resident in care.

Official plan of correction

Administrator agreed to provide a statement of understanding for the regulation cited. Administrator will send a blank copy of the 30-day advanced notification of room change notice they will using in the facility via email by the POC date.

Deadline recorded: Nov 10, 2023. A deadline is not proof that correction was completed.

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 has not been met as evidenced by observation the facility has broken tiles which poses a potential safety risk to this resident in care.

Official plan of correction

Administrator agreed to provide pictures of fixed floor by the POC date.

Deadline recorded: Nov 10, 2023. A deadline is not proof that correction was completed.

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 has not been met as evidenced by observation the broken LPM observed towels on the floor which poses a potential safety risk to this resident in care.

Official plan of correction

Administrator agreed to provide a copy of the new protocol regarding soiled linens issued and signed by staff and email a copy by the POC date.

Deadline recorded: Nov 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705(f)(2) Care of persons with Dementia Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA's observation chemicals used for cleaning where left unattended in a hallway in the designated memory care unit accessible to residents in care which poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The Administrator agreed to purchase either a lock box or carts with compartments that lock Proof of purchase and picture must be submitted to LPA by POC date.

Deadline recorded: Oct 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on observation, record review and interviews conducted, facility staff failed to meet the needs of resident (R1) and (R2) who required incontinant care and S1 was the only staff observed in the memory care unit to provide assistance which poses an immediate safety risk to this resident in care.

Official plan of correction

Administrator agreed to (1.) submit a staff schedule that addresses the supervision of residents in the memory care unit. When applicable resident’s care plans shall be updated, and staffing scheduling shall be reevaluated. (2.) Submit proof of future staff training i.e., needs and services of residents, resident care, and supervision.

Deadline recorded: Oct 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

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 has not been met as evidenced by:

Official plan of correction

Administrator agreed to lock all the propane tanks and hire a professional company to treat pests issue.

Deadline recorded: Oct 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(k)(2)

Regulation authority

CCR

What the official deficiency says

87705(k)(2)The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of delayed egress devices. This requirement has not been met as evidence by LPA's observation. Facility failed to notify CCLD and provide a complete LIC 200 form within the appropriate time frame

Official plan of correction

Administrator agreed to sumbit LIC 200 by the POC date and email the LPA a copy of complete LIC 200.

Deadline recorded: Oct 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

(a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: based on LPAs obervation the facility failed to provide hygine items to residents.

Official plan of correction

Administrator agreed to purchase new non skit matts and provide picture of new loofahs/bath cloths for residents and provide enough towels for the capacity of the facility and trash pins with lids in the shower rooms. Administrator will submit to LPA a proof of purchase and a picture of towels and loofas by the POC date

Deadline recorded: Oct 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) 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 is evidenced by LPA's observed the floor panels had been removed making the floor uneven. The toilet tank cover was missing in bathroom #1. In the kitchen there was a large puddle of water on the floor coming from a leak in the industrial dishwasher. This poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator will email a snap shot of the repairs completed.

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

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. This was evidenced by: LPA observed eight resident files and observed the Physician's Report for Residential Care Facilities for the Elderly were missing from the residents; files which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator will obtain the Physician's report for the eight residents' files.

Deadline recorded: Mar 17, 2023. 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

(b) the following food service requirements shall apply: (26) Supplies of nonperishable food for a minimum of one week & perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by: Based on observations by LPA the Licensee did not comply with the section cited above by not ensuring the required minimum of 7-days nonperishable and 2 days perishable supply of food was maintained on the premises. This poses an immediate health and safety or personal rights risk to clients in care.

Official plan of correction

Licensee/Administrator will purchase groceries to meet the minimum requirement on the regulation cited and send a picture of receipt and groceries to LPA by POC date 02/24/2023.

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

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish...(1)A written report...(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...This requirement was not met as evidenced by: Based on interview and record review the Administrator did not comply with the section cited above as evidence by the administrator's own admission an incident report was not submitted to Community Care Licensing Division (CCLD) when R1 shoved her and R1 was taken to the hospital.

Official plan of correction

Administrator will submit an incident report for the incident described on this report and a written statement that all incident reports will be reported in a timely manner by poc due date 03/03/2023.

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

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) 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 was not met as evidenced by: Based on interviews and observation, conducted by LPA the licensee did not comply with the section cited above by failing to maintain resident's #2 (R2) room in good repair. Ceiling tile in R2's room 117 is drooping.

Official plan of correction

Licensee/Administrator will ensure in house maintenance repair ceiling tiles in R2's bedroom. A picture of the fixed ceiling submitted to LPA by POC date 03/03/2023.

Deadline recorded: Mar 3, 2023. 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

87555 General Food Service Requirements (b) the following food service requirements shall apply: (26) Supplies of nonperishable food for a minimum of one week & perishable foods for a minimum of two days shall be maintained on the prmises. This requireement is not met as evidenced by: Based on LPA's observations, the facility has a shortage of both perishable and non-perishable food items which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

The Business Officer Manager will provide a photo to LPA of purchased perishable and non-perishable foods. The Business Office Manager will provide LPA a copy of the December facility menu.

Deadline recorded: Dec 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary at all times. Maintenance shall include...mainte- nance services & procedures for the safety and well-being of residents. This requirement is not met as evidenced by: LPA observed bed bugs in R1's bed during LPA's tour of the facility, which is an immediate health and safety risk to residents in care.

Deadline recorded: Nov 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(b)(2)

Regulation authority

CCR

What the official deficiency says

87470(b)(2)-Infection control requirements - 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 touring the facility, LPA observed five staff members were not wearing a mask which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will remind staff and will place signs throughout the facility as a reminder to wear masks

Deadline recorded: Aug 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87761(d)

Regulation authority

CCR

What the official deficiency says

When a facility is cited for a deficiency and violates the same regulation subsection within a 12-month period, the facility shall be cited and an immediate penalty of $250 per cited violation shall be assessed for one day only. Thereafter a penalty of $50 per day, per cited violation, shall be assessed until the deficiency is corrected. Immediate Civil Penalty of $250.00 was assessed on 8/20/2015.

Official plan of correction

Administrator will ensure staff are reminded to wear masks for entire shift.

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

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services (d) The following space & safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair & shall provide a safe & healthful environment. This requirement was not met as evidenced by: Based upon LPA's interview of a staff member and observation of two resident room keys were actual master keys, the allegation is substantiated and is an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will instruct maintenance staff member to change the lock for three rooms that were checked.

Deadline recorded: Jul 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(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 touring the facility, LPA observed four staff members were not wearing a mask which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will conduct a training reminding staff of the need to wear masks and also review proper donniing and doffing of all PPE. Administrator will provide sign in sheet with staff member's signature after training has been conducted.

Deadline recorded: Jun 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1, ... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, ...This requierment was not met as evidenced by: Based upon LPA's interviews of the Administrator and Caregiver, Caregivers were not aware the resident had left the building without an escort, which is an immediate health and safety risk to residents in care.

Official plan of correction

Administrator has already counseled the caregiver in question. Administrator has reviewed the facility procedures with the Caregiver and a documented verbal warning was issued to the caregiver.

Deadline recorded: Apr 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Services. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Los Angeles County Department of Health LVN professionals witnessed the medication was left out and accessible to anyone who walked into the room. Facility staff did not insure the medication was properly taken by a resident to which is an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will conduct proper training regarding medication distribution to ensure this incident will not occur again.

Deadline recorded: Mar 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(2)

Regulation authority

CCR

What the official deficiency says

All staff and volunteers providing direct care to a resident who has a communicable disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents... PPE may include gloves, gowns, masks, etc. This requirement was not met as evidenced by: Los Angeles County Dept. of Health LVN professionals witnessed caregiver did not wear full PPE.

Official plan of correction

Administrator will review Regulation 87470 Infection Control Requirements with all staff.

Deadline recorded: Mar 18, 2022. 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 - (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 upon LPA's interviews of ten residents, licensee failed to ensure the care of residents was met. Six of the ten residents interviewed stated had to wait over thirty minutes for a diaper change. Three residents stated only checked two times a day during the 7:00 am until 7:00 pm shift and one resident stated had to wait over two hours for a assistance.

Official plan of correction

Administrator stated a new caregiver will begin training tomorrow. The shift will be 10:00 am to 6:00 pm. The caregiver's additional responsibility will be supervision of the current caregivers. Administrator stated will be hiring an additional caregiver upon determination of a qualified person.

Deadline recorded: Dec 28, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care ..of adequate hygiene practice shall be... available to each resident. (D)Clean linen,... bath towels, hand towels and wash cloths. This requirement is not met as evidenced by: Based on LPA Spaeth's inspection of seven residents' rooms, there were no hand towels or paper towels provided for residents' use in each residents' bathroom.

Deadline recorded: Nov 15, 2021. A deadline is not proof that correction was completed.