HUMBLE HAVEN RCFE IV

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed the laundry detergent & construction tools were not locked in a safe location, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction LPA observed the caregiver locked the laundry room door.

Official classification

Type B

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on resident file review, the licensee did not comply with the section cited above in three out of four residents, which could pose a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2025 Plan of Correction The Administrator will send copies of the completed pre-appraisals for the three residents (R1-R3) and forward the documentation to LPA Spaeth via email.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on resident file review, the licensee did not comply with the section cited above in three out of four residents, which could pose a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2025 Plan of Correction The Administrator will send copies of the completed appraisals for the three residents (R1-R3) and forward the documentation to LPA Spaeth via email.

Official classification

Type A

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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. Two out of the five residents' files did not contain the physicians's report (LIC 602) which poses an immediate health, safety risk to persons in care.

Official plan of correction

POC Due Date: 11/11/2024 Plan of Correction The Licensee will send the LIC 602 for the two residents via email to LPA Spaeth

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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. Two out of the five residents' files did not contain an appraisal, needs assessment which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/11/2024 Plan of Correction The Licensee will send the appraisal needs assessments for the two residents via email to LPA Spaeth.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations & Services (d) the following space & safety provisions shall apply…(2) The premises shall be maintained in a state…and shall provide a safe and healthful environment . This was evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. Within bedroom 5, an empty additional bed was in the room and was blocking the exit out the door which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction LPA observed the additional empty bed was removed during LPA's visit.

Official classification

Type A

Official code

87303(3)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance & Operation e water supplies & plumbing fixtures shall be maintained…(2) Faucets used by residents for personal care….Hot water temperature controls shall be maintained….to a temperature of not less than 105 degrees F & not more than 120 degrees F… This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited. The water temperature was 131.00 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction During the tour, the hot water temperature to the hot water tank was lowered. LPA Spaeth tested the temperature again at 11:00 am and the temperature was 110 degrees f.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

87202(a)(2) All facilities shall maintain a fire clearance approved by fire dept... Prior to accepting any of the following types of persons, licensee shall obtain an appropriate fire clearance approved by fire dept, (2) Bedridden persons. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited above. A bedridden resident is in a non-ambulatory room, The resident is in the wrong room, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2024 Plan of Correction The Licensee will move to the resident to Room 5, which is designated as a bedridden room.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidenced by: Based on audit review of records, the licensee did not comply with the section. LPA identified staff #3 did not have a Criminal Clearance Background Clearance Transfer associated at this facility. This violation poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to ensure that all staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by POC due date. Proof of Correction due date: 05/19/24 to ernand.dabuet@dsss.ca.gov *A CIVIL PENALTY IS BEING ISSUED TODAY 05/18/24*

Deadline recorded: May 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by: Based on [(observation) (interview) (record review)], the licensee did not comply with the section. The facility is approved for (3) hospice waiver and is now operating with (4) hospice residents beyond the conditions and limitations specified on the license. This violation which poses an potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee agreed to request for hospice waiver increase request to CCLD by correction date 05/31/24 understands that it is their responsibility to follow up on waiver requests and hospice residents should not reside at the facility until a hospice waiver is granted by CCL. Plan of correction must be submitted by 05/31/24 to ernand.dabuet@dss.ca.gov

Deadline recorded: May 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above . LPA identified staff #2 & #3 did not have a current First Aid/CPR Training. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will ensure that all staff involved with resident's daily care must have a current First Aid/CPR training. Proof of correction must be sent to by POC due date: 05/31/24 to ernand.dabuet.@dss.ca.gov

Deadline recorded: May 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. 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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited above The water temperature was recordeded to be 141.1 Degrees F at 11:45 am which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction During LPA's visit, the caregiver reduced the water heater temperature. LPA tested the water again at 12:30 pm and the temperature was 107.0 degree F.

Official classification

Type A

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. The garage had been converted into a room and a resident was living in the room. Also, CCL did not receive a copy of the building permit which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/04/2024 Plan of Correction The Administrator has been advised to provide the building permit to LPA Spaeth via emal.

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, there are seven residents living in the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2024 Plan of Correction The Administrator has been instructed to relocate the resident to another location.

Official classification

Type A

Official code

87307(e)

Regulation authority

CCR

What the official deficiency says

(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed the spa cover was not properly on the spa, .

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction During LPA's visit, the spa cover was placed on top of the spa. .

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's obsevations, the licensee did not comply with the section cited above. LPA observed cleaning solutions were stored underneath an unlocked bathroom cabinet which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction During LPA's visit, the cleaning solutions were locked in a bathroom cabinet.

Official classification

Type A

Official code

87606(c)

Regulation authority

CCR

What the official deficiency says

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed there are two bedridden residents and the facility has a fire clearance for one bedridden resident. The room disgnation for a bedridden client is room 5.

Official plan of correction

POC Due Date: 03/27/2024 Plan of Correction The Administrator will move resident No. 2 to the correct room. The Administrator stated the Physiciani's Report for Resident No 1 is incorrect. The Administrator will obtained an new Physician's Report which will identify resident No 1 as ambulatory so that resident No. 1 can remain in Room one.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (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: Deficient Practice Statement Based on LPA Spaeth's observation, the caregiver had left personal medication on a dresser which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction During LPA's visit, LPA observed the caregiver locked personal medications in the locked medication cabinet.

Official classification

Type A

Official code

87705(k)

Regulation authority

CCR

What the official deficiency says

(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. The egress alarms had been turned off, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction During LPA's visit, the alarms to three exits were turned on. At 3:30 pm, LPA observ all three alarms were operable.