EVA'S CARE HOME IN LANCASTER LLC

Official classification

Type A

Official code

87355(d)(3)

Regulation authority

CCR

What the official deficiency says

(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in 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 one (1) out of three (3) staff not finger printed for background clearance prior to employment which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2024 Plan of Correction Licensee will not allow S1 to return to work until fingerprints are submitted for background clearance. Once complete Licensee will inform LPA once S1 is on Guardian Background Check System cleared and associated to this facility.

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 record review, the licensee did not comply with the section cited above in 3 out of 3 staff records which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2024 Plan of Correction Licensee will provide copies of staff's health screening along with TB test results to LPA by POC due date 09/13/2024.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 resident #2(R2) having a full length bed rail even though they are not receiving Hospice services which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2024 Plan of Correction Licensee informed LPA they will submit a request for an exception as resident is a fall risk. LPA informed Licensee facility must be in compliance while they seek an exception. Licensee will remove full length bed rail and request half rail while exception letter is reviewed.

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 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. 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 R2, a resident with dementia not having an annual medical assessment completed timely, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2024 Plan of Correction Licensee informed LPA they will work with R2's family to schedule a doctors appointment for R2 for an updated medical assessment. Licensee will submit a copy of R2's updated physician's report/medical assessment to LPA by POC due date 09/13/2024.

Official classification

Type A

Official code

87470(c)(1)(F)

Regulation authority

CCR

What the official deficiency says

87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement was not met as evidenced by: Based on observations the licensee did not comply with the cited section by not screening LPAs for symptoms of COVID 19 upon entry and staff where not wearing masks, which poses and immediate Health and Safety and personal rights risk to persons in care.

Official plan of correction

Licensee shall ensure all staff will attend infection control training to be provided by an individual trained in infection control. Proof of training shall be signed by each staff and submitted by the POC due date of 6/29/2022.

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

Official classification

Type A

Official code

87705(f)(1)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) 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 observation, the licensee did not comply with the section cited above. LPA observed sharps, medication and cleaning supplies to be accessible to residents in care which poses and immediate Health and Safety and personal rights risk to persons in care.

Official plan of correction

The Administrator has locked all the sharps and medications. This part of the plan of correction was met during the visit. The Administrator has agreed to provide training to all staff on the importance of maintaining medications, sharps and chemicals inaccessible and the administrator shall submit staff sign in sheet with the topic and the training material.

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