MARY ELLEN HOMES

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) 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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as bedroom #1 to contained an unsecured box of prescription medications which posed an immediate health or safety risk to persons in care.

Official plan of correction

POC Due Date: 02/18/2026 Plan of Correction Administrator secured the medication at the time of the visit. POC cleared.

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 record review, the licensee did not comply with the section cited above as four residents files contained appraisal needs and service plans that were not updated within the last 12 months which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/18/2026 Plan of Correction Administrator complete an updated appraisal needs and service plan for each identified individual at the time of the visit. POC cleared.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as three resident's medications were prepared one week in advance utilizing a Monday-Sunday pill organizer which poses a potential health or safety risk to persons in care.

Official plan of correction

POC Due Date: 02/19/2025 Plan of Correction Administrator removed the pills from the organizers at the time of the visit. Administrator agreed to not prepare resident's medications more than 24 hours in advance. POC cleared.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited aboveas two resident's medical assessments did not contain proof of a negative TB test which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 03/05/2025 Plan of Correction Licensee will submit proof of negative TB tests for the identified residents to CCLD no later than POC due date.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as one resident was observed to be absent from the facility while out on a walk without staff assistance while their medical assessment indicated that they are unable to leave the facility unassisted which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/05/2025 Plan of Correction Licensee will submit a statement of understanding to CCLD confirming that they understand the importance of following physician's orders and providing appropriate care and supervision to residents. Licensee may submit an updated medical assessment indicating that the resident is able to leave the facility unassisted. Licensee will submit documents no later than POC due date.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance(e)(1): All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department . This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as the licensee did not ensure that S2 was associated prior to allowing S2 to work, which poses an immediate health and safety risk to persons in care.

Official plan of correction

Licensee agreed to only employ staff that have obtained a criminal record clearance and are associated to the facility. Administrator understands that the individual cannot be present at the facility until they have obtained criminal record clearance.

Deadline recorded: May 12, 2023. A deadline is not proof that correction was completed.