DURANDO HOME II

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation,interview and record review, the licensee did not comply with the section cited above in 2 out of 3 staff files checked were missing staff training records which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2026 Plan of Correction The Licensee/Administrator will review the regulation and email LPA Segovia a statement of understanding, and the process of staff training documentation for all staff on the LIC 500 by POC due date.

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 observation,interview, and record review, the licensee did not comply with the section cited above in 4 out of 4 residents were missing their Reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/23/2026 Plan of Correction The Licensee/Administrator will review the regulation and email LPA Segovia a statement of understanding and the reappraisals for all four residents by POC due date.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 4 residents were missing an updated medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2026 Plan of Correction The Licensee/Administrator will review the regulation and email LPA Segovia a statement of understanding and the updated medical assessments for the 3 residents.

Official classification

Type B

Official code

87609(b)(4)

Regulation authority

CCR

What the official deficiency says

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 resident receiving home health service, the Administrator/Licensee could not provide information nor documentation pertaining to services being provided which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/23/2026 Plan of Correction The Licensee/Administrator will review the regulation and email LPA Segovia a statement of understanding by POC due date.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care.(a) ...routine medical and dental care and provide for assistance in obtaining such care... (1)The licensee shall arrange, or assist in arranging, for medical and dental care... This requirement is not met as evidenced by: Based on interviews and Record review the licensee did not ensure that four of the four residents received their health appointments as needed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee will review the regulation and email LPA Segovia a statment of understanding including documentation confirming the process of updating R1's dental insurance by POC due date.

Deadline recorded: Dec 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 in 1 out of 1 documentation of Liability Insurance not available or expired which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/20/2024 Plan of Correction Administratorr will email LPA Segovia a copy of their most current Liability Insurance by Friday (12-20-24)

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Walls in facility in disrepair/and not clean/window screens missing/ripped Deficient Practice Statement Based on observation the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/08/2024 Plan of Correction Administrator will submit photos of correction

Official classification

Type A

Official code

87470(c)(1)(F)

Regulation authority

CCR

What the official deficiency says

87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and... This requirement is not met as evidenced by: Based on an interview and LPA observation the licensee/administrator confirmed that during a previous visit conducted by the credible witness, staff did not comply with the section cited above by not wearing masks, which poses an immediate Health and Safety and personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator agreed to provide in house training with all staff regarding Infection Control Requirements and COVID Protocol. A written statement signed by all staff regarding such training shall be emailed to LPA no later than 01/28/23.

Deadline recorded: Jan 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement has not been met as evidenced by facility staff failing to observe resident’s pressure injury, allowing for it to progress to a wound greater than a stage II. This possesses an immediate health and safety risk to the resident in care.

Official plan of correction

As POC, licensee will review this section with their staff and certify that they have read and understood regulation. As proof of POC, the licensee will submit signed documentation that they have reviewed and understand this section of the regulation. POC is due by 6/16/22.

Deadline recorded: Jun 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement has not been met as evidenced by the licensee failing to replace the resident’s home health services after her contract with her previous home health agency had expired. Contiinue }

Official plan of correction

This poses as an immediate health and safety risk to the resident in care. As POC, licensee will review this section with their staff and certify that they have read and understood regulation. As proof of POC, the licensee will submit signed documentation that they have reviewed and understand this section of the regulation. POC is due by 6/16/22.

Deadline recorded: Jun 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. The licensee failed to follow the infection control protocol on screening procedures. Staff was not familiar with screening procedures, thermometer was not operating properly and no symptom screening questions have been asked, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2022 Plan of Correction Licensee agreed to train all staff on Mitigation Plan and infection Control which includes screening. Staff sign-in sheet and training materials shall be e-mailed to LPA by POC date.