OUR SWEET HOME INC #2

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

Bed rail 87608(a)(3) (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. R2 has half a rail without a doctor's order. The doctor's note only included DME without specifying the use of a half rail. This poses/posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2025 Plan of Correction Administrator will provide doctor's oder for R2 using half rail bed by the POC date.

Official classification

Type B

Official code

87458(c)(1)

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: 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. R4 and R5 don't have an updated physician report which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/02/2025 Plan of Correction Administrator will provide update physician report for R4 and R5 by the POC date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on LPA's observation and record review, the facility failed to provide records, showing medications were provided to R1 from 12/17/2021 to 01/06/2022 which poses an immediate health and safety risk to the residents in care.

Official plan of correction

Review of residents medication records for the month of May 2022 were noted as in compliance by LPA Martinez. Review of medication and medication records for April 2024 reviewed by LPA Rios are in compliance. Based on current medication compliance administrator will provide to LPA a statement of understanding for the cited regulation by POC due date.

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

Official classification

Type B

Official code

87216(a)

Regulation authority

CCR

What the official deficiency says

Bonding: (a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file, or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.

Official plan of correction

The Licensee will obtain a required surety bond. A proof of adequate bond will be submitted to CCL BY POC due date

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87215

Regulation authority

CCR

What the official deficiency says

Commingling of Money: Money and valuables of residents entrusted to the licensee of one community care facility licensed under a particular license number shall not be commingled with those for another residential care facility for the elderly of a different license number, regardless of joint ownership.

Official plan of correction

Licensee agrees to provide a copy of the bank statement showing P & I funds have been deposited into a trust account. Submit by POC due date.

Deadline recorded: May 10, 2022. 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

Safeguards for Resident Cash, Personal Property, and Valuables. (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. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by not retaining receipts for items purchased with residents P & I which posed a personal rights violation to residents in care.

Official plan of correction

The Licensee will refund P & I funds to two (1) residents of Brilliant Corners as described in Audit report and furnish Regional Office and Brilliant Corners proof of repayment. The documents must be provided to CCLD by POC due date.

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Every facility shall account for any cash resources entrusted to the care or control of the licensee or facility staff. (1) Cash resources include but are not limited to monetary gifts, tax credits and/or refunds, earnings from employment or workshops, and p ersonal and incidental need allowances from funding sources such as SSI/SSP. This requirement is not met as evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by not distributing P & I funds to residents (R1), and not keeping proper records of funds entrusted to her which posed a personal rights violation to residents in care.

Official plan of correction

Licensee agrees to: 1. Pay back residents (R1) P & I amounts due. Licensee owes: Resident (R1) $3,159; Submit proof (bank statements) that the amounts due were issued to R1.

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(e)

Regulation authority

CCR

What the official deficiency says

(e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability the licensee incurs in the use of his own or the facility's funds and valuables. This requirement was not met evidenced by: Based on record review and interview conducted during the audit investigation the licensee did not comply with the cited section by commingling facility funds with personal and incidental funds. This posed/poses a personal rights risk to persons in care.

Official plan of correction

Licensee/administrator agrees to open a bank trust account for the residents P & I and deposit residents' P & I funds into the trust account only. Facility bank account should not have any residents' P & I monies. Provide copies of bank statements showing P & I funds have been deposited into a trust account.

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2-3)(d)

Regulation authority

CCR

What the official deficiency says

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (3) Ability to maintain or supervise the maintenance of financial and other records (5) Good character and a continuing reputation of personal integrity. This requirement was not evidenced by: Based record review and interview conducted during the audit investigation the Licensee failed to maintain accurate financial records; and provided DHS and CCL inaccurate documentation and information.

Official plan of correction

Licensee/Administrator will schedule vendorized training related to the cited section as well as all other sections cited on this report Verification of scheduled training with the trainers credentials will need to e submitted by 4/29/2022 and completed by 5/13/2022.

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87207

Regulation authority

HSC

What the official deficiency says

False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility

Official plan of correction

Licensee/Administrator will schedule vendorized training related to the cited section as well as: 87408: Denial or Revocation of a Certificate; 87777: Exclusions: Personal Rights.

Deadline recorded: Apr 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Maintenance and Operation(e)(2) Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:Water temperature meaured at 130.8 degree F. Based on water temperature measurement, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Deadline recorded: Mar 18, 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

8730 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 requirement is not met as evidenced by: Garage is overfilled with bulk items, Patio flooring poses a tripping hazard to the residents and one bathroom floor is in disrepair, which poses a health, safety or personal rights risk to persons in care.

Deadline recorded: Mar 31, 2022. A deadline is not proof that correction was completed.