GOLDEN MANOR RETIREMENT CENTER

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation All window screens shall be clean and maintained in good repair. This requirement was not met as evidenced by: Facility failed to have window screens in good repair in resident room 35 sliding door screen and Room 45 window screen which posed a potential Health and Safety Risk to residents care.

Official plan of correction

Facility to submit proof of repair of window screens by POC due date.

Deadline recorded: Jun 6, 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. This requirement was not met as evidenced by: Facility failed to have the resident's mattress in good repair in Room 77 which posed a potential Health and Safety Risk to residents care.

Official plan of correction

Facility to submit proof of repair of resident's mattress by POC due date.

Deadline recorded: May 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: 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 is not met as evidenced by: Licensee failed to ensure that medication was kept in a safe and locked space with inhaler observed in R1's room which posed an Immediate Health and Safety concern.

Official plan of correction

Facility to submit by POC due date training regarding medication management and submit signed log of who had attended. Administrator at visit submitted a Training Log pertaining to medication management that was conducted on 10/02/24. Deficiency cleared.

Deadline recorded: Oct 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 25 out of 25 staff, as the last disaster drill was conducted on 2/15/2024, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction Administrator is to ensure that a disaster drill is conducted once every 3 months. Administrator is to conduct a new fire drill and email LPA the participants of the drill by the POC due date.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities 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 interviews conducted licensee failed to ensure that resident's be accorded dignity in their personal relationships with staff, with 3 staff harassing R1 by going to their room about the rent which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to review regulation regarding Personal Rights of Residents in All Facilities and conduct a staff training regarding personal rights and submit a signed log of those who attended by POC due date.

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

Official classification

Type B

Official code

87219(d)

Regulation authority

CCR

What the official deficiency says

Planned Activities In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies. Copies shall be retained for at least six (6) months. This requirement is not met as evidenced by: Licensee failed to post activities calendar as confirmed by 6 of 6 resident's, observation by LPA and confirmation by administrator which poses an Immediate Health and Safety Concern to resident's in care.

Official plan of correction

Facility to post Activity's calendar and submit by POC due date proof that it is posted.

Deadline recorded: Sep 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(f)

Regulation authority

CCR

What the official deficiency says

Planned Activities In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers. This requirement is not as evidenced by: Licensee failed to have one staff member having full time responsibility to organize, conduct and evaluate planned activities with 6 of 6 resident's stating there are not group activities being done which poses an Immediate Health and Safety Concern to resident's in care.

Official plan of correction

Facility to submit to Licensing by POC due date staff member to have full time responsibility of activities and submit verification of 1 year experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers.

Deadline recorded: Sep 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(6)

Regulation authority

CCR

What the official deficiency says

General food Service Requirements The following food service requirements shall apply: In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. This requirement is not met as evidenced by: Facility at today's visit had menu posted dated 08/20 to 08/26 which is not the current week which poses an Immediate Health and Safety Concern to resident's in care.

Official plan of correction

Administrator to self-certify that all menus posted will be current and submit by POC due date.

Deadline recorded: Sep 5, 2023. 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

Personal Rights of Residents in All Facilities 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 interviews conducted licensee failed to ensure that resident's be accorded dignity in their personal relationships with staff, with 3 staff harassing R1 by going to their room about the rent which caused an immediate health and safety concern to resident's in care.

Official plan of correction

Facility to review regulation regarding Personal Rights of Residents in All Facilities and conduct a staff training regarding personal rights and submit a signed log of those who attended by POC due date.

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

Official classification

Type B

Official code

87218(a)(2)

Regulation authority

CCR

What the official deficiency says

Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153. This requirement has not been met as evidenced by: Resident #2's new pants were missing from her room which was confirmed by the Administrator in which it was not included in the residents personal property, or valuables which causes an Immediate Health safety Risk to residents in care.

Official plan of correction

The licensee will ensure to help monitor and safeguard all of the residents property and valuables while in care. The licensee/Administrator will replace residents #2's item that is missing and submit receipt by POC due date..

Deadline recorded: Jun 27, 2022. 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 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 evidence by: Based on interviews conducted licensee did not ensure residents are not threating at facility as 5 out of 8 residents have observed residents threating other residents which poses an immediate health, safety, or personal rights risk of persons in care.

Official plan of correction

Administrator will provide in-service training to staff and residents on section 87468.1 and submit a copy of the agenda and sign in log to the department by 6/13/22.

Deadline recorded: Jun 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by; During the visit conducted on 2/24/212, LPA Trueman toured the courtyard of the facility facility and based on statements obtained, LPA learned that residents have been observed smoking marijuana in the courtyard area. This poses an immediate Health and safety Risk to residents iin care.

Official plan of correction

Administrator will review Title 22 Regulations Section 87468.1 on Personal Rights of Residents in All Facilities and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Mar 21, 2022. 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

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. Based on observation, interviews, and record review, the elevator is currently not working which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee will ensure the elevator is in good repair/operable and submit proof of invoice showing the repairs made. The POC must be submitted to CCL by the due date of 03/16/22.

Deadline recorded: Mar 16, 2022. 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 observations and interviews the facility failed to have the facility in good repair at all times with Room 1 having a sliding door that was inoperable and didn't slide open which caused an Immediate Health and Safety Risk to residents in care,

Official plan of correction

Facility to submit proof by POC due date that sliding door in Rooms 1 and 3 are fully operable and in good repair.

Deadline recorded: Dec 20, 2021. A deadline is not proof that correction was completed.