Licensing and administrationType A
- Official classification
- Type A
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on the record review, the licensee did not comply with the section cited above in three out of three persons did not have cpr certification which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/14/2025 Plan of Correction CPR is to be reviewed and conducted and copies of CPR certification is to be sent to LPA.
Records and plan of operationType A
- Official classification
- Type A
- Official code
- 87212(b)(2)(A)
- Regulation authority
- CCR
What the official deficiency says
(b) The plan shall be subject to review by the Department and shall include: (2) Plan for evacuation including: (A) Fire safety plan. This requirement is not met as evidenced by: Deficient Practice Statement Based on the observations the licensee did not comply with the section cited above in one out of one fire extinguisher was expired which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/14/2025 Plan of Correction A new fire extinguisher is to be bought and a copy of the receipt is to be sent to LPA.
Fire safety and emergency preparednessType B
- 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 the record review, the licensee did not comply with the section cited above in a quarterly fire or/and earthquake drill conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/20/2025 Plan of Correction A copy of the fire/earthquake drill shall be sent to the LPA and a copy is to be kept in the facility binder.
Dementia careType B
- Official classification
- Type B
- Official code
- 87705(e)(6)(B)
- Regulation authority
- CCR
What the official deficiency says
(e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: (6) For each incident of elopement, as defined in Section 87101, Definitions, the licensee shall report the incident to: (B) The licensing agency Officer of the Day, by telephone, e-mail, fax, or hand-delivery no later than the next working day following the incident. If reported by telephone, a written report shall also be submitted to the licensing agency as specified in Section 87211, Reporting Requirements. The report shall be added to the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on the interview and record review the licensee did not comply with the section cited above in one out of one resident who died within the last annual review and was not reported to CCLD which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/20/2025 Plan of Correction An Unusual/Incident/Death report is to be sent to CCLD within 24 hours/and or seven days notifying CCLD of any death and/or resident injuries.